This page presents Chapter 3 of: Byrne, J.W. (2018) How to Write a New Life for Yourself: Narrative therapy and the writing solution. Hebden Bridge: The Institute for E-CENT Publications.
Chapter 3: Therapeutic Narratives and Writing Therapy: The two main traditions and the E-CENT approach
Pennebaker (1997)[i] says:
“For the past decade, an increasing number of studies have demonstrated that when individuals write about emotional experiences, significant physical and mental health improvements follow …”
In this chapter, we begin by identifying a major problem for humans. We are born into families within communities, and those groups speak a language and promote a discourse, or conversation, about the nature of life, and our place and role in that world. We are thus dominated from childhood by narratives and stories that are not our own, in the sense of being consciously chosen or designed by us, individually, to promote our own interests.
This situation has both strengths and weaknesses, or good and bad aspects. The strength or goodness of this situation is that this is how we develop and disseminate an agreed social morality, which is essential for the wellbeing of the family and community. The weakness or badness of this situation is that racist, sexist and classist elements (or other unreasonable or immoral restraining elements) are normally built into those stories which we imbibe with our mother’s milk. Thus the possibilities for the development of our potential are normally constrained by the social status accorded to us in the story into which we are enrolled in early childhood.
Furthermore, we run the risk of buying into later stories, from subcultures, and elements of the mass media, which will further oppress and distort us.
This chapter may be of interest to all readers, but perhaps more so to the professional helpers – like counsellors, psychotherapists, psychologists, social workers, and others – who want to introduce their clients to writing therapy.
We humans are colonized by our mothers at birth, and develop our sense of self out of our dialectical interactions with her, and with our fathers; and later with siblings, peers, neighbours, other relatives, etc. We create mental maps, or schemas and stories, about our cumulative, interpretative social experiences. This process is unavoidable – it could not be otherwise – but the details of the stories we imbibe and create may often need to be reviewed when we are older, to see if we can develop more self-helping stories to guide our lives.
We are story tellers in a sea of stories, as fish are aquatic beings in a sea of water. The fish does not see the water and cannot swim beyond the limits of the body of water in which they are immersed; just as the human being does not see the sea of language in which we are immersed, and also cannot ‘swim’ (or think-feel-act) beyond our linguistic stories, schemas, scripts, frames, etc.
But our stories are not just left-brained, linguistic, cool-cognitive narratives. They are emotionally significant and meaningful representations of some aspect of our felt experience of interacting with our social and physical environment. They involve thinking-feeling-perceiving-acting components. And they are socially shaped, and/or modified by social experience.
Some of the (non-conscious) narratives that control our lives induce misery and mental suffering, and some are healing and therapeutic; while still others help us to know how to be good citizens and moral individuals.
Individuals may need to explore and resolve many issues from the past, and this can be done in the form of spoken narratives with a therapist, or written narratives as ‘homework activity’ outside of counselling sessions; or even as self-directed narrative writing.
There is a range of options for the structure of therapeutic writing activities.
One possibility could involve an individual in writing for 3-5 minutes, about a problem that is bothering them. Then they might edit their work, for 15-20 minutes. In the process they could look for causal links between events; and reflect on their own role in the creation of the problem. They would also be well advised to use more positive than negative words, and to end with some kind of coping self-statement, to avoid feelings of hopelessness and helplessness.
Other possible strategies are discussed above, and later in this book.
More generally, a therapeutic narrative is any kind of written or spoken narrative or story which promotes physical and/or mental healing.
Writing therapy, on the other hand, is any system of writing that is designed to promote psychological and physical wellbeing.
There are two ways of classifying the schools of thought in writing therapy.
- According to Bolton, Howlett, Lago and Wright (2004), there are two basic traditions in writing therapy: the cognitive/scientific tradition, and the creative/humanities tradition. Both are found to be effective.
- However, according to McLeod (2003), pages 227-238[ii]; plus McLeod(1997/2006), chapters 3 to 5, there are three approaches to narrative therapy in counselling and therapy. These are: (1) the psychodynamic approach; (2) the cognitive/ constructivist approach; and (3) the social constructionist approach. Each of these would have a slightly different approach to writing therapy.
The best way to reconcile these classifications is this: Classification 2 is about approaches to narrative therapy (both written and spoken) in counselling and therapy; and Classification 1 is specifically about writing therapy, and not always in counselling and /or therapy contexts.
Writing therapy is highly effective, compared with drug treatments, but the mechanism by which writing therapy works is still unclear. Some people have argued that it might just be that the opportunity to express a problem that has been bottled up is curative in itself and Pennebaker, 1997 agrees with this view.
Elsewhere, Pennebaker and colleagues have mainly emphasized that it is the thinking through of a problem, which has not previously been thoroughly digested, that produces the therapeutic effect. But these two processes actually overlap and complement each other: expressing it, and digesting it; both in language (either spoken to a helpful person, like a counsellor; or written out in a constructive form).
Effective writing therapy seems to involve processing previously unprocessed negative emotions, in a self-reflective way; naming them; and identifying causal links between elements of the story. It also normally involves using more positive than negative words, and ending with a coping self-statement. And of achieving gradual refinement of the narrative, in terms of emerging meanings.
Writing therapy seems to be a viable option for most people, but normally excluding people who are: seriously depressed; or highly stressed; or suffering from PTSD; or people who have negative associations with writing at school.
It probably appeals most to people who enjoy writing, and who are self-reflective.
So counsellors and therapists should be careful and selective when deciding whether or not to recommend writing therapy to a client.
In this section, I will be dealing with the writing of therapeutic narratives. I set out to answer the following questions:
What is a therapeutic narrative?
What is writing therapy?
Is writing therapy effective?
Who should use therapeutic writing? And:
How should an individual guide their own therapeutic writing?
Before we look at these questions, we need to ask: What is the problem?
The problem is that the human mind is dominated by language, or, at the very least, strongly influenced by language and stories. Most of our emotional distresses and disturbances are woven into memories of social experiences, represented visually, viscerally (in our guts and heart and lungs), and in language-based stories that work against us.
Corey (2001) makes a similar point – summarizing the Narrative Therapy position developed by Epston and White (1990):
“…individuals construct the meaning of life in interpretive stories, which are then treated as ‘truth’. The construction of meaning can happen monologically (by oneself) or dialogically (with others), with the latter having the greater power in our lives because we are social beings. In this sense, an individual is most often a socially constructed narrative system”.
Although we normally are strongly influenced by socially constructed narrative schemas (or scripts, stories, frames, etc.), which means that we live inside of individually constructed and socially constructed stories in our heads and bodies, we also live in a real world – a concrete reality – and our negative or depowering stories produce negative and depowering consequences for us in our lived experience. Or as Corey (2001) puts it: “The process of living our story is not simply metaphorical; it is very real, with real effects and real consequences in family and societal systems. Families are small social systems with communal narratives that express their values and meanings, which are embedded in larger systems, such as culture and society”. (Page 431).
We are born as feeling beings, with innate ‘affects’, or ‘basic emotions’. (Byrne, 2018). We are then colonized by our mothers at birth, and socially conditioned into a range of belief systems, at home, in school, in our peer relations, via the media, and so on. (Byrne, 2009).
Corey says: “Because people are systems within systems within still other systems, they can easily lose freedom. Therapy is, in part, a reestablishment of individual and family freedom from the oppression of external problems and the dominant stories of larger systems”. (Page 431).
A similar argument is presented by Jordaan and Nolte (2010):
“The dominant narrative presents the established and accepted story of a community or a person’s life. Such narratives shape and structure societies, eventually becoming dominant ideologies that are, in turn, maintained by these dominant/master narratives (see Adam 1995; Breytenbach 1997; …Lyotard 1984; …)”.
From the beginning of our lives, we (as living organisms) create schemas, or symbolic representations of our experiences: which are auditory, visual and kinaesthetic. These are abstractions from ‘the real world’, or ‘symbolic representations’ of interpretative experiences. Or, as Jordaan and Nolte (2010) say:
“The social anthropologist, Clifford Geertz (1973:87–125), describes people’s worlds as ‘symbol systems’. These are combinations of symbols and language and serve as models for everyday life. Models function on two levels, namely as an expression of how life is structured and lived, as well as a blueprint for coming generations for how life should be lived in their own or other societies, such as the one represented in the accepted symbol system (Petersen 1985)”.
It is a misleading, incomplete statement to say that, “These are combinations of symbols and language…” Why? Because language cannot be separated out from the feelings and automatic perceptions of the agent experiencing them. My inner world is both physical-chemical-electrical, and symbolic. But the symbols are constructed from auditory-visual-kinaesthetic engrams (or memory records) of thinking-feeling-perceiving, which is always and indivisibly emotive-cognitive-and-embodied, and linked to (and regulated by) a social environment.
Humans do not know they are (emotive-cognitive-embodied) story tellers, living in a world of stories – any more than fish know they are aquatic creatures, swimming through a body of water – and that is the problem (for humans). As Jordaan and Nolte (2010) say: “These systems/narratives are powerful because they are accepted as truth and objective reality. T.O. Beidelman (1971), an anthropologist …, shows that societies structure themselves in terms of shared ways of behaviour, which build upon ways in which people perceive themselves and the worlds they live in. People communicate these convictions through language, but Beidelman (1971:30) also says: ‘by language I mean far more than grammar, syntax, and vocabulary. What I mean is the sum total of ways in which the members of a society symbolise or categorise their experience so that they may give it order and form and thereby manipulate it and also deal with their fellows who share this experience with them.’ The dominant narratives are usually handed down from generation to generation and are thus largely unquestioned (Epston & White 1990).”
This is a multi-generational problem, with a long cultural history. The dominant ideology, or narrative, in every culture tends to be an expression of powerful vested interests – such as the maintenance of slavery, or female submission, or the power of financial institutions, or the under-education (or ‘dumbing down’) of the masses, or the yoking of the individual to the sole aim of consuming commodities, and on and on.
“Dominant narratives are ideologically immersed; however, they can usually be summed up in simple one-liners, for example ‘masters are better than slaves’, or ‘apartheid is God-given’.” (Jordaan and Nolte, 2010).
The only way to displace or defeat a dominant narrative is to substitute an alternative narrative.
The alternative narrative is often implicit within the form of construction of the dominant narrative. However, the alternative narrative is often buried deeply and resisted, even by the oppressed individual, family or community. For example, the dominant narrative that oppresses a deprived family in a high-unemployment working-class housing estate might be internalized as this: ‘We are no good, and we have earned our fate by our worthlessness’. However, the alternative narrative might be that they did not invent the class structure of their society, and they did not have any of the advantages that their middle class detractors had. But it is very difficult to assert the alternative narrative when the dominant narrative is repeated like a mantra in the daily newspapers and on the TV and radio.
In describing the working of Narrative Therapy, as developed by Epston and White (1990), Jordaan and Nolte (2010) describe a ‘storied therapy’ as follows:
“This begins with a story that has gone wrong due to a certain dominant narrative. Another challenging narrative emerges. A problem is identified and externalized. These problems are usually related to the bodies of certain people considered inferior versus others considered superior. A new story is then compiled, based on…examples from the past” – where the ‘victim’ was able to rise above their disempowerment and function well in the world. (Jordaan and Nolte, 2010).
In E-CENT counselling, we combine the Epston and White approach with the psychodynamic approach; the gestalt approach; the expressive and the creative/reflective traditions; plus some new and original ideas of our own. But what emerges is our own unique approach, which differs in as many ways as it conforms to the ideas that gave rise to it.
“Writing and thinking go hand in hand”. Lago (2004: Page 104)
A therapeutic narrative is a piece of writing (and/or, in its broadest sense, a spoken monologue or dialogue) – normally in the form of a story – which helps to heal the mind of the writer/author/speaker. A great deal of fiction – including novels, plays and short stories – has been written for this purpose: to heal the author; or to help them to get over a significant emotional block or deprivation.
Therapeutic texts show up in many formats – e.g. personal journals, emails to counsellors, letters written but never sent, etc. – and they tackle many different kinds of personal challenges. They are always about some kind of recovery, or growth, or personal liberation from restriction or suffering.
For example, Julia Cameron (1992) teaches a daily writing process that is designed to help the writer recover a sense of safety and identity; a sense of power and integrity; a sense of possibility and abundance; a sense of connection and strength; a sense of compassion and self-protection; etc.
Those goals are achieved by writing three pages of ‘stream of consciousness’ each day (‘free writing’); plus reading her book chapters; and completing various exercises.
This is a ‘stream-of-consciousness’ process, in which you give expression, in writing, to whatever thoughts, feelings, attitudes, concerns, worries, or whatever, that happen to float up into conscious awareness. This gives you access to creative thoughts, problem solutions, and useful insights.
“Morning Pages are three pages of longhand, stream of consciousness writing, done first thing in the morning. *There is no wrong way to do Morning Pages* – they are not high art. They are not even ‘writing.’ They are about anything and everything that crosses your mind – and they are for your eyes only. Morning Pages provoke, clarify, comfort, cajole, prioritize and synchronize the day at hand. Do not over-think Morning Pages: just put three pages of anything on the page…and then do three more pages tomorrow.”
If you want to experiment with this process, just begin to write. Just whatever comes up in your mind.
If you are blocked, write this: “I am blocked. I am blocked. I am blocked”.
If you don’t know what to write, write this: “I don’t know what to write. I don’t know what to write. I don’t know what to write.”
Just keep going – writing whatever comes up – until you have filled three pages of A4 writing pad, and then stop!
According to Bolton and Wright (2004):
“Therapeutic writing is of great value within medicine, healthcare, many branches of psychotherapy, occupational therapy, care of the elderly, substance abuse rehabilitation, community development, social inclusion, race relations, care of asylum seekers and victims of torture, adult education and education of children who have a range of difficulties”. That is a highly selective list, and it would not be difficult “…to extended (it) to include any form of support of people of any age over 5 who experience any social or psychological difficulties”. (Page 229).
The question then arises: What does therapeutic writing consist of, or include?
This was summarized by Bolton and Wright (2004) as follows:
“Therapeutic writing employs processes of personal, explorative and expressive writing, which might also be creative or literary, in which patients or clients are offered guidance and inspiration by a clinician or creative writer, and help in choosing a topic for their writing.
This might also take the form of approaches similar to ‘guided fantasy’, or it might take the form of something more like an ‘essay topic’, or structured writing tasks”.
This is a much freer and more idiosyncratic approach than the cognitive/scientific approach of Pennebaker (1997).
According to Bolton and Wright (2004): “Each person is encouraged to work in a way that accords with their own interests and concerns, and according to their own felt wants and needs. Authority and control of each piece of writing resides with the writer”.
The products of writing therapy are not designed to please an audience:
“Whereas literary writing is oriented towards a literature product of as high a quality as possible (e.g. poetry, fiction, drama), generally aimed at an unknown audience, the emphasis of therapeutic writing is on the process of writing to create material of satisfaction and interest to the writer, and possibly to a few close individuals. Occasionally no final product may be created”. (Pages 228-229).
That still leaves the question of what kinds of areas people are likely to want to work on in a narrative text. This can be very wide-ranging:
– In E-CENT counselling, we focus on a few key stories: the story of personal origins; the story of relationships; the story of transitions; the story of present problems; and so on. (See Chapter 4, below for guidelines for writing these therapeutic stories).
– In the training of counsellors at diploma level, journal writing is often used as a vehicle for personal development of the trainee counsellor.
In that context, the areas for consideration in their own personal development can include any of the following items:
Table 3.1 Areas for personal development, from Daniels and Feltham (2004):
|Target area||Reflective questions|
|Behaviour, will, motivation||What do I avoid, or do to excess?|
|Feelings and sensations||What are my most typical, valuable or troublesome feelings and bodily sensations? What changes could I make? How?|
|Imagery||How aware am I of creative or intrusive images, metaphors, dreams, nightmares? How can I explore, understand or change these?|
|Cognition (thinking)||What part does rationality (or irrationality), analysis and intellectual development, play in my life? What changes can I make?|
|Somatic (bodily) awareness||How aware am I of health issues (diet, nutrition, sleep, and physical fitness), the place of sport, dance, appearance, etc.?|
|Interpersonal||How sociable or solitary am I? Am I satisfied with the quality of my relationships? Do I have ‘unfinished business’ from childhood or other relationships? Do I want to increase my social skills? How?|
|Practical-technical||What strengths and problems do I have in negotiating the everyday world? Do I want to change anything? How?|
|Sexuality||Am I happy with my sex life and sexual orientation? To what extent am I fulfilled? Are there any changes I can make or want to make?|
|Socio-political||How aware and involved am I in ‘personal politics’; and/or my local community; and/or macro-politics? Do I want to be more active?|
|Spiritual-existential||What is my attitude to the ‘big questions’ of life? Am I engaged in any meditation, prayer, search for meaning, etc.? Do I want to be?|
|Untapped potential||Have I ignored or downplayed aspects of myself? Do I have ‘wasted’ musical or other talents? How might I develop these?|
|Self esteem||To what extent do I have low self-esteem? Can I accept myself regardless of how much I achieve (or don’t achieve) of my self-defined aims for personal development?|
I have presented this list in full because it seems to be a pretty comprehensive agenda for almost anybody to consider in terms of their personal development challenges, and not just counsellors.
Just about anybody could choose several of these topics for the subject of their therapeutic narrative writing exercises.
Choose one or two of the target areas for personal development listed in the table above. Use the suggested reflective questions, plus any questions you can generate yourself, to write about where you are up to with a particular target area, and what your developmental needs or wants might be.
Therapeutic writing is also used by professionals in their reflective practice activities. As Bolton, Allan and Drucquer (2004) explain:
“Writing is useful for stress management, helping to avoid burnout and lowered performance: ‘Writing is a disinhibition strategy, as it anchors people to a safe present while they re-experience a past event, providing optimum distance possibilities and hence cathartic reset’ (Evison, 2001: 256)”.
The first draft of a piece of therapeutic writing can be further developed over time to expand it into relevant areas of consideration for reflective practice purposes. Normally, the first stage: “…is followed by a more cognitive process of reading and redrafting the writing to make sure it covers as much range as possible”, according to these authors. “Reflective practice writers need to ensure that they’ve covered what they did, what they thought and what they felt.” If this work is being done in a group setting, then “there follows the stage of reading the writing aloud to peers in a trusted, carefully facilitated forum. The audience are using artistry in their response”. (Page 198).
This approach can also be used in group therapy, but an audience is not essential, beyond the reading by a counsellor or psychotherapist. But in the most basic of cases, there is no reader other than the author.
Here’s one humanistic approach to writing therapeutic texts, from Bolton, Allan and Drucquer (2004), describing the groups run by Gillie Bolton:
“In the groups I run we laugh quite a lot, as well as cry.
And people feel enriched by having created (a piece of narrative), and being involved in the creativity of others.
“How to start:
- “Only 20-30 minutes is needed to do a useful piece of writing: if much longer is set aside, much of it will be wasted in fiddling about without starting to write.
- “You will write the right thing, no matter what you write; you can’t write the wrong thing (by definition).
- “Write without thinking: let the writing hand take charge.
- “Forget all the rules of grammar, structure, form and spelling ever learned. If these do need sorting out before the writing is shared, it’s easier done later.
- “First write whatever comes into your head for six minutes without stopping, and without thinking. There is no theme or subject for this stage: the aim is to capture those images, which flash in and out of the mind with little or no attention paid to them. This might come out like lists, scattered bits and bobs, or even be fairly incomprehensible.
- “Now take a theme, such as: a time I learned something vital; a gift; someone who was very important to me. Tell a story or write a poem about a time when… Write for about 20 minutes or more.
- “Read it all through silently (including the six-minute scribble). Improve upon the content if that seems right, but give no thought to grammar, construction or spelling yet. Look out for useful connections between the six minutes and the longer writing.
- “Share it with another, if and when that seems right.
- “Now this is an exciting stage, if you venture this far: write a fictional story or poem which complements the original one. Write in the voice of the person at the centre of the original account: the patient, the colleague or the relative. Or rewrite giving the account a satisfactory ending instead of a horrid one, or switching the gender of the main characters. Or write in another genre: Mills & Boon (Romantic Fiction), thriller, detective, fantasy… There are many different ways to write another story or poem as there are writers: experiment, have fun. This is a very instructive stage.” (Pages 207-208).
According to Steinberg (2004)[iii]: “Written words can raise goose pimples (bumps): they work, when even the most appropriate of physical treatments, dietary therapies and psychological approaches haven’t succeeded”. There is now substantial research to support this conclusion, from both laboratory studies, clinical studies, and self-reports from writing therapy clients. “The vitality of words may have something to do with the nature of language and the magic of storytelling and poetry in a way that reaches well beyond psychological theories into the fundamental qualities of being human, and which may underpin or short-circuit treatments”. (Steinberg, 2004: page 44).
This is the essence of what are called therapeutic narratives.
(But please bear in mind: Writing therapy cannot cure things which need dietary changes; or increased physical exercise; and enhanced sleep. Writing can only cure those things which can be cured by writing! [See Byrne, 2018]).
Above I have written about what a therapeutic narrative is, and it is clear that, if a novel or a poem, or a conversation with a friend, can be a therapeutic narrative, then there is a distinction to be made between therapeutic narratives per se, and the processes of ‘writing therapy’ – even though writing therapy’s main product may be therapeutic narratives.
A therapeutic narrative is clearly any kind of written or spoken narrative/story which promotes physical or mental healing.
Writing therapy, on the other hand, is any system of writing that is designed to promote psychological and physical wellbeing.
Writing therapy is seen as positing that, when a person writes about their negative feelings from the past, including traumatic and stressful experiences, the result is an easing of physical and emotional pain, and a strengthening of their immune system: (Woolston, 2000)[iv].
The neuropsychology of this change process may be, as argued by James Pennebaker, “…that when we write, we are tacking between the right and the left hemispheres of the brain – one that holds memory, and one that holds the story-telling drive…” (Noppe-Brandon, 2018). And what this may do is to reorganize and reintegrate the “narrative self” and the “somatic self”. (Siegel, 2015).
Woolston (2000) described the case of John Mulligan, a homeless Vietnam veteran suffering from post-traumatic stress, and sleeping on the streets of San Francisco, living out of a shopping trolley. Mulligan attended one workshop on writing therapy, took to writing out all his ‘psychological demons’, and persisted with this daily practice for a number of years. This helped Mulligan to integrate his wartime horror story experiences in Vietnam, and he concluded that: “Writing about stressful events can be powerfully therapeutic for mind and body”. (Page 1, Woolston, 2000). In the process he rehabilitated himself, and went on to become a successful novelist[v].
On the other hand, Wright (2004)[vi] says that:
“Defining ‘writing therapy’ is difficult: it is ‘a useful but vague and poorly defined technique…’ in Riordan’s (1996: 263)[vii] summary.
Neither is there one set theoretical model or set of empirical findings to guide the use of therapeutic writing. References to parallels with other expressive and creative therapies, art, movement, drama and music, for example, are clear but there is little systematic explanation as to why writing therapy has not developed to the same extent.
For the purposes of this review, I will define writing therapy as ‘client expressive and reflective writing, whether self-generated or suggested by a therapist/ researcher’. Therefore, the use of writing by the therapist about the client, such as in case notes or in farewell letters, is not included”. (Page 8).
Then again, according to Lowe (2004), writing in the cognitive psychology and biomedical tradition:
“Many studies have shown that people feel happier and healthier after writing about deeply traumatic memories. Actively confronting upsetting experiences – through writing or talking – reduces the negative effects of ‘bottling things up’, which can lead to long-term stress and disease. But what are the links between confronting traumatic events and long-term health?” (Page 18).
According to Pennebaker (1997): “A process common to most therapies is labelling the problem and discussing its causes and consequences. Further, participating in therapy presupposes that the individual acknowledges the existence of a problem and openly discusses it with another person. As discussed in this article, the mere act of disclosure is a powerful therapeutic agent that may account for a substantial percentage of the variance in the healing process”. (Page 162).
Emotive-Cognitive Embodied Narrative Therapy (E-CENT) subscribes to the idea that the disclosure of emotionally difficult material is central to the curative effects of therapeutic writing. Our inference is that the process of getting in touch with previously undigested emotional experience has the effect of ‘completing them’, allowing them to be, and thus integrating them into the client’s set of stable, functional schemas[viii]. However, before this can happen, there is often the difficult problem of integrating two conflicting schemas – or two narratives into one – or displacing a negative, dominant narrative with a new, alternative and liberating one. Jordaan and Nolte (2010) summarize this process very neatly when they say: “(Narrative therapy) is the re-establishment of personal agency from the oppression of external problems and the dominant stories of larger systems (Corey 2005)[ix]. Therapy occurs when the dominant narrative is effectively challenged by an alternative narrative; if the dominant narrative is not challenged and dealt with accordingly, there can be no therapy”.[x]
There seem to be two basic, but broad, traditions within modern writing therapy, dating from around 1970 – although therapeutic journal writing goes back well before that date – and those two traditions are the cognitive/scientific paradigm (e.g. Pennebaker and Beall, 1986[xi]; Pennebaker, 1990[xii], 1995[xiii], 2002[xiv]), and the humanistic or humanities approach (e.g. Bolton, Allan and Drucquer, 2004[xv]; Wright, 2004[xvi]). Wright (2004) refuses to come down in favour of either of these two broad camps: “If anything, I would agree with Mazza (1999)[xvii] that both approaches are needed in order to develop the research base and professional practice of writing therapy”. (Wright, 2004: Page 8).
One way to distinguish the cognitive/scientific paradigm and the humanities approach is to refer to the former as ‘expressive writing’ and the latter as creative/poetic/reflective writing; however these are not precise lines of demarcation, but suggestive labels. According to Baikie and Wilhelm (2005)[xviii], Pennebaker’s expressive writing research approach “…involves participants writing about traumatic or emotional experiences (…) for 3-5 sessions, often over consecutive days, for 15-20 minutes per session. Most studies have been conducted in a laboratory, although more recently writing has been done at home or in a clinical setting. Participants often reveal a considerable range and depth of emotional trauma in their writing. Although many (research participants) report being upset by the writing experience, they also find it valuable and meaningful: (Pennebaker, 1997[xix]).” Pennebaker’s research involves the use of ‘control groups’ to see how much the real therapy groups improve relative to an ‘untreated group’. “Control (group) participants are asked to write as objectively and factually as possible about neutral topics such as a particular room or their plans for the day, without revealing their emotions or opinions. No feedback is given on the writing”. (Baikie and Wilhelm, 2005)[xx].
Here is an example of how Pennebaker and his colleagues direct their research participants in the expressive writing tradition, from Pennebaker (1997):
“For the next 3 days, I would like for you to write about your very deepest thoughts and feeling about an extremely important emotional issue that has affected you and your life. In your writing I’d like you to really let go and explore your very deepest emotions and thoughts. You might tie your topic to your relationships with others including parents, lovers, friends, or relatives; to your past, your present, or your future; or to who you have been, who you would like to be, or who you are now. You may write about the same general issues or experiences on all days of writing, or on different topics each day. All of your writing will be completely confidential. Don’t worry about spelling, sentence structure, or grammar. The only rule is that once you begin writing, continue to do so until your time is up”. (Page 162).
So writing therapy involves writing about emotional traumas, or troublesome emotional stories from the past: in order to stop bottling them up; to begin to digest them; to begin to displace unhelpful dominant narratives, and replace them with more helpful and less disturbing alternative narratives; to integrate conflicting narratives; and so on.
But just how negative should we aim to be in our writing therapy work? And do positive emotion words also play a part? Pennebaker (1997) has found some interesting patterns relative to these questions: “Analyzing the experimental subjects’ data from six writing studies”, he says, “we found three linguistic factors reliably predicted improved physical health. First, the more that individuals used positive emotion words, the better their subsequent health. Second, a moderate number of negative emotion words predicted health. Both very high and very low levels of negative emotion words correlated with poorer health. Third, and most important, an increase in both causal and insight words over the course of writing was strongly associated with improved health. … Indeed, this increase in cognitive words covaried with judges’ evaluations of the construction of the narratives. That is, people who benefited from writing began with poorly organized descriptions and progressed to coherent stories by the last day of writing”. (Page 165).
Therefore we can say that an individual who uses writing therapy to:
# clarify and refine a confused and unclear story from their past;
# who uses a moderate amount of negative words, in order to express their trauma or distress,
# combined with a higher volume of positive words,
# to describe a reframing, or alternative positive narrative; and
# who seeks to understand who or what caused what effects in their past,
# resulting in new insights about their past, spread over a period of time
# by writing increasingly clear or coherent narratives;
# that individual will most likely reap a good reward in terms of improved physical health and emotional well-being.
How can you apply these insights in planning and managing your own writing therapy work?
This is not a complex process, and many variations on the theme could be developed to suit the various schools of thought in counselling and therapy. Despite all the apparent complexity of the cognitive/scientific paradigm of writing therapy research, the process itself is quite simple. As Wright (2004: 12) says:
“The simplicity of the way in which writing therapy works, if not the precise mechanism, is expressed humbly, after a dense analysis of randomized controlled trials, as follows:
‘Many people, perhaps most, are able to guide their own therapy. Writing itself is a powerful therapeutic technique’. (Esterling et al. 1999: 94)[xxi].
It can also, often, be very helpful to have a coach, counsellor or psychotherapist to support the individual in their journey through their writing therapy challenges.
According to Wright (2004: 8): “… (Pennebaker’s and others’) experiments clearly demonstrate the benefits of ‘writing therapy’ in reducing inhibition and improving both physical and mental health (e.g. Francis and Pennebaker, 1992[xxii])”. This refers to the research on the effectiveness of writing therapy undertaken by Dr James Pennebaker, at Southern Methodist University, USA.
For example, Pennebaker (1997)[xxiii] says:
“For the past decade, an increasing number of studies have demonstrated that when individuals write about emotional experiences, significant physical and mental health improvements follow …”
This research has been spread across a number of sites, and the common theme has been that when individuals confront their emotional demons, they reap rewards in terms of physical and emotional well-being, plus improvements in their social behaviours. Or, as Pennebaker (1997) expresses it: “…several laboratories have been exploring the value of writing or talking about emotional experiences. Confronting deeply personal issues has been found to promote physical health, subjective well-being, and selected adaptive behaviours”. (Page 162).
Pennebaker and his associates have not been able to pin down the causal link between writing and its therapeutic effects, but Pennebaker (1997) presents a hypothetical causal link as follows:
“A process common to most therapies (involves) labelling the problem and discussing its causes and consequences. Further, participating in therapy presupposes that the individual acknowledges the existence of a problem and openly discusses it with another person. As discussed in this article, the mere act of disclosure is a powerful therapeutic agent that may account for a substantial percentage of the variance in the healing process”. (Page 162).
Pennebaker’s research does show, using various laboratory tests, that students who wrote about traumatic events had improved immune system functioning, and reported having an improved sense of well-being. This did not occur in the case of students who wrote on neutral topics. (Pennebaker, 1997).
Daniels and Feltham (2004)[xxiv] explored the effectiveness of journal writing as a form of personal therapy and personal development for trainee counsellors. This is what they concluded about the effectiveness of this process:
“When asked about the benefits of journal writing itself, without comparison to other approaches to personal development, even though some trainees were sceptical to start with, all found great value in it, as demonstrated in the following quotations:
‘Seeing them (my feelings) on paper also helps me to understand them.
‘Looking back and seeing how I’ve grown (helps).
‘Reading back all of it was really beneficial, makes me realize how busy I am etc.
‘(It)… gives me personal satisfaction, without the need to necessarily prove myself to others by having work published or read by others for approval’.
‘It gives you the chance to have a rational debate with yourself, often enabling you to correctly put issues into focus, perhaps for the first time’.
Daniels and Feltham (2004) continue like this:
“Few disadvantages were identified and these were concerned mainly with the lack of available feedback and challenge, and also with fears around the permanency of the writing: ‘I can’t take it away and forget what is written’. Difficulties expressed were identified in terms of time, including setting aside sufficient time, and the vulnerability of self-disclosure. … Trainees were also worried about losing focus: ‘Sometimes I don’t have an issue to explore and I waffle about nothing’. Although stream of consciousness works effectively as a format, it is also useful to have the periodic reminder of potential areas for personal development…” (See Table 3.1 above). This review of the humanities approach to writing therapy is very positive.
The humanities approach also draws evidence from the cognitive/scientific tradition to support their own work: “The beneficial effects of written emotional expression are … clearly and precisely recorded and have been subjected to meta-analysis (Smyth, 1998)[xxv]. Reviews of core research on written emotional expression and health (Pennebaker, 1997; Esterling et al., 1999; Lepore and Smyth, 2002[xxvi]) suggest various benefits (see Lowe, 2004 for more detail). Headlines such as ‘the pen is more powerful than the pill (Bower, 1999) have drawn popular attention to the efficacy of writing (as therapy)”. (Wright, 2004).
Lowe (2004) reiterates the benefits of writing therapy referred to in the reviews of Pennebaker, Esterling and others. He also adds that “Individuals who showed the greatest improvements in health were those who wrote about topics that they had actively held back from telling others. The use of more self-reflective and causal thinking, from the first to the last day of writing led to greater health improvements, in terms of lower symptom reports and fewer doctor visits”: (Page 19). Thus it seems that more ‘self-regulatory’ individuals, who identify possible coping steps to deal with the problems about which they have written, gain the most from writing therapy: (Lowe, 2004, page 19; and Cameron and Nichols, 1998[xxvii]).
Despite all the apparent complexity of the cognitive/scientific paradigm of writing therapy research, the process itself is quite simple. As Wright (2004: 12) says: “The simplicity of the way in which writing therapy works, if not the precise mechanism, is expressed humbly, after a dense analysis of randomized controlled trials, as follows: ‘Many people, perhaps most, are able to guide their own therapy. Writing itself is a powerful therapeutic technique’. (Esterling et al. 1999: 94)[xxviii].
We have now defined ‘therapeutic writing’ and ‘writing therapy’, and shown that writing therapy is highly beneficial to most people in terms of promoting physical and mental well-being, and adaptive behaviour. However, not everybody is likely to benefit equally from writing therapy, and so it is important to try to identify those situations and circumstances in which writing therapy would be seen to be helpful, and also those situations and circumstances in which writing therapy would be contra-indicated.
(a) Who is most likely to benefit from writing therapy, and in what circumstances?
Wright (2004:14) has summarized a list of client circumstances in which writing therapy seems most appropriate, combined with some evidence from the literature, as follows:
Table 3.2 (from Wright, 2004: 14): Circumstances in which writing therapy is beneficial, (with) supporting evidence
|Clients’ circumstances||Some supporting studies|
|1. Time-limited, focused, brief therapy – some of the detail can be dealt with outside the therapy room, on paper in private.||Advantages of ‘economy and complexity’ (e.g. Ryle 1983: 365[xxix]; Rasmussen and Tomm, 1992)[xxx].|
|2. With people who have a self-directed tendency to write – journals, diaries, letters – and who have found the process of writing, especially autobiographical writing, (to be) cathartic and clarifying.||Examples from literature (e.g. Adams 1990[xxxi], 1996[xxxii]; Brewer 1994[xxxiii]; Gilbert 1995[xxxiv]; De Salvo 1999[xxxv]).|
|3. With people who are or perceive themselves to be powerless.||Bacigalupe (1996)[xxxvi]; case material in Wright (2000)[xxxvii].|
|4. With people who are not using their first language in the face-to-face therapy – they are able to use their first language or a mixture of both first and host language.||Lago (2004)[xxxviii]; Wright (1999)[xxxix].|
|5. With people who, for cultural or other reasons, are silenced by shame and feel unable to speak.||Bass and Davis (1988)[xl]; Bolton (1996b)[xli]; Etherington (2000)[xlii].|
|6. With people who are in inner turmoil and need to ‘unpack the mind’, externalise and organise their thoughts and feelings.||L’Abate (1992)[xliii]; Riordan (1996)[xliv].|
|Clients’ circumstances||Some supporting studies|
|7. With people who need to disclose and exorcise a particular memory of stressful or traumatic experience.||Pennebaker paradigm reviewed in Smyth (1998)[xlv]; Amsterdam Writing Group; Bolton (1999a[xlvi], b); Lepore and Smyth (2002)[xlvii].|
|8. With people at particular stages of life associated with experiencing strong feelings (e.g. adolescence or for the dying and those in hospice care).||Sosin (1983)[xlviii]; Atlas et al. (1992)[xlix]; Longo (1996)[l]; Bolton (1998)[li]; Lepore and Smyth (2002)[lii].|
It might also be that this form of therapy is particularly suitable for, or particularly helpful to, males more so than females:
“Smyth’s (1998) meta-analysis found that the effects (of writing therapy) were greater for males than for females. Expressive writing is more beneficial for those high in alexithymia … (or inability to understand, describe or process emotional states – JB) and high in splitting[liii] … Suggesting potential for the use of expressive writing in these populations”: Baikie and Wilhelm (2005).
This does not mean it is not helpful to females, but just that it may be most helpful to males, and females who are alexithymic. But it has efficacy across the sexes.
(b) Who should be excluded from writing therapy processes for their own protection?
According to Wright (2004), writing therapy is not appropriate in all circumstances. For example: “When the client’s experience is pre-verbal (from the first couple of years of life – JB), … other expressive therapies would be preferred. When writing is associated with strong negative experiences, for example in English classes at school, clients are unlikely to want to try writing therapy. One such client, to whom I had suggested (a particular form of letter writing – JB) said, ‘I don’t want to read or write about my experiences’. The initial negative mood and short-term psychological pain resulting from writing about traumatic events … may be intolerable for some unsupported writers (e.g. online)”. (Page 12).
There is also a specific warning from Lowe (2004), based on a review of the work of Gidron et al. (1996)[liv], to the effect that “…written disclosure without coping skills should not be recommended for PTSD patients”. (Lowe, 2004: page 20)
Furthermore: according to Howlett (2004)[lv]: “While writing can do much to augment, enrich and facilitate face-to-face therapeutic work, it is important for the therapist to use it judiciously, ensuring that it does indeed play this enhancing role.” (Page 93).
Depressed, highly stressed or suicidal clients, or those suffering from PTSD, should not be asked to engage in unsupported writing therapy: “Wright (2004) and Lowe (2004) refer to the need for caution in suggesting writing to clients suffering from chronic depression, (or) who are highly disturbed, psychotic or suffering from post-traumatic stress disorder. Writing can be used to obstruct and divert from the therapeutic task.”
Writing therapy should also be avoided with clients who are in denial about their problems, and who may seek to divert the therapist at every turn: “Some clients bring reams of writing which, if it were read by the therapist at the time, would take up most of the session and avoid the possibility of engagement within the therapy room. It may also mean that all emotional expression takes place outside the sessions, where it can be safely sealed off, rather than being shared and worked with (or worked through – JB)”. (Pages 93-94). Thus with some clients, or at certain stages in a particular client’s therapy, it might be better to stick to face to face encounters.
Clients who are high on Adapted Child ego state may also go along with writing therapy assignments, when they are not actively interested or engaged in the process: “In (these) cases there may be a passive compliance with writing assignments, which are then done ‘for the therapist’, and paradoxically absolve the client from taking an active role in engaging with their own issues”.
Counsellors and therapists should be careful when, how and with whom they use writing therapy: “It is always important for the therapist to be alert to potential pitfalls, and to find ways of addressing them or bringing them into the therapeutic dialogue”. (Howlett, 2004, page 94).
Therapeutic writing can be used on your own, or with the support of a therapist or counsellor in writing therapy; or with the guidance of a trainer in a writing therapy workshop.
You should be clear that:
(a) Writing therapy will cause you to feel worse in the short term, as you complete your undigested traumatic or painful experiences from the past.
(b) In the longer term, digesting and completing those experiences is likely to make you feel much better, to allow you to think clearer, to act better, and to have better emotional and physical health.
You should not attempt self-directed writing therapy if you are severely depressed, suicidal, suffering from PTSD, and/or prone to psychotic symptoms. To see if self-directed writing therapy is right for you, please check Table 3.2 above.
In deciding what to write about, you could consult Table 3.2, above. Or you could use the guidelines set by Pennebaker (1997), above. Or, finally, you could use the story structure recommended in E-CENT: the Story of Origins; the Story of Relationship; the Story of Current Problems; etc. (See Chapter 4, below).
Aim to use a moderate amount of negative words; a much greater number of positive words; and always try to end with a coping self-statement, such as:
‘It could have been worse!’
‘Life is both difficult and non-difficult! So remember the non-difficult bits!’
‘It is not the worse possible outcome. And if I cannot control it, I had better learn to accept that it happened’.
‘I can stand having this kind of problem in my life/history’.
‘Life is difficult for all human beings, at least some of the time!’
‘I will not damn (that person) or myself because of what he/she/I did. Though I might make a moral judgement about their behaviour; or report them to the police for unlawful action (if I judge that to be the right course of action to take)’.
‘When it rains (in my life), I just let it rain! (Because rain is uncontrollable! But you can try to normally have an umbrella handy!)’
‘I will learn to cope better with this problem’. Etc.
If you are going to use writing therapy as a self-directed activity, make sure you have a backup, in the form of a local counsellor/therapist who can help and support you if you become overly distressed.
(a) For therapists and counsellors: The following learning points are most relevant to counsellor, psychotherapists, psychologists, psychoanalysts, social workers, etc.:
(1) There is a problem with the stories that clients carry around in their minds. The dominant narratives in their lives may be persecutory or self-downing or otherwise undermining of their self-esteem and distorting of their self-concept.
(2) Alternative narratives can be developed which are more empowering, and which have a therapeutic effect on the body and mind of the client.
(3) The challenging of dominant or unhelpful narratives can be done verbally or in writing.
(4) Writing therapy is highly effective, relative to drug therapy.
(5) Guidance is presented on who would benefit most from writing therapy, and who should be excluded from the process for their own protection.
(b) For individuals interested in self-help and personal development: There are at least three learning points that are relevant to individuals who want to work on their own self development, as follows:
(1) You can use writing therapy to help you to express previously repressed stories of trauma and emotional pain, deprivation, and so on.
(2) Guidelines are presented for the individual reader who wants to engage in self-directed writing therapy.
(3) You might also decide it is safest to have a counsellor or therapist lined up in case you experience great emotional distress.
(c) For counselling and psychotherapy students: If you are studying counselling and therapy in a college, there is a good chance that you will be asked to keep a Personal Development Journal in which you will record those challenges you faced, the key learning points that you encountered, and so on, on your journey of growing into the role of counsellor/psychotherapist. This book can help this process in the following ways:
(1) By providing you will a list of key areas to consider for your personal development, in Table 3.1 above.
(2) By describing three approaches to working in your journal:
(A) The cognitive/scientific approach described by Pennebaker (1997), near the end of Section 4, above.
(B) The reflective/humanities approach, described by Bolton, Allan and Drucquer (2004), beginning on the page following Table 3.1, above.
(C) Or the E-CENT approach of writing about the story which is of most concern to you at the moment: the Story of Origins; the Story of Relationship; the Story of Transitions; the Story of Present Problems; and so on. (See Byrne, 2016b, for my story of origins and my story of relationship with my mother).
(3) And by providing guidelines for how to structure your writing, in Section 7, above.
For more, please see the mother page, How to Write a new Life for Yourself.***
[i] Pennebaker, J.W. (1997) Writing about emotional experiences as a therapeutic process. Psychological Science, 8(3): 162.
[ii] McLeod, J. (2003) An Introduction to Counselling. Third edition. Buckingham: Open University Press.
[iii] Steinberg, D. (2004) From archetype to impressions: the magic of words. In: Bolton, G., Howlett, S., Lago, C. and Wright, J.K. (eds.) Writing Cures: an introductory handbook of writing in counselling and therapy. Hove, East Sussex: Brunner-Routledge.
[iv] Woolston, C. (2000) Writing for therapy helps ease effects of trauma. CNN.com news. Available online: http://archives.cnn.com/2000/health/03/16/health.writing.wmd/. Accessed: 12th April 2010.
[v] Mulligan, J. (1997) Shopping Cart Soldiers. New York: Scribner/Simon & Schuster. (Paperback novel)
[vi] Wright, J. (2004) The passion of science, the precision of poetry. In: Bolton, G., Howlett, S., Lago, C. and Wright, J.K. (eds.) Writing Cures: an introductory handbook of writing in counselling and therapy. Hove, East Sussex: Brunner-Routledge.
[vii] Riordan, R.J. (1996) Scriptotherapy: therapeutic writing as a counseling adjunct. Journal of Counseling and Development, 74: 263-269.
[viii] I have previously defined ‘schemas’ as ‘packets of information’; or maps and models that allow us to know how to perceive and act within specific types of contexts; such as eating in a restaurant as opposed to a quick visit to a ‘greasy spoon’ café. Or how to speak in the presence of a respected female as opposed to ‘mucking around with the boys’.
[ix] Corey, G. (2005) Theory and practice of counselling and psychotherapy, Belmont, CA: Thompson Brooks/Cole. (Cited in Jordaan and Nolte, 2010)
[x] Jordaan, P.J., Nolte, S.P., (2010) Reading Philemon as therapeutic narrative, HTS Teologiese Studies/Theological Studies 66(1), Art. #307, 6 pages. DOI: 10.4102/hts.v66i1.307
[xi] Pennebaker, J.W. and Beall, S.K. (1986) Confronting a traumatic event: toward an understanding of inhibition and disease. Journal of Abnormal psychology, 93(3): 274-281.
[xii] Pennebaker, J.W. (1990) Opening Up: the healing power of confiding in others. New York: Avon Books.
[xiii] Pennebaker, J.W. (ed) (1995) Emotion, Disclosure and Health. Washington, DC: American Psychological Association.
[xiv] Pennebaker, J.W. (2002) Writing about emotional events: from past to future. In: S.J. Lepore and J.M. Smythe (eds) The Writing Cure: How expressive writing promotes health and emotional well-being. Washington, DC: American Psychological Association.
[xv] Bolton, G., Allan, H. and Drucquer, H. (2004) Writing for reflective practice. In: Bolton, G., Howlett, S., Lago, C. and Wright, J.K. (eds.) Writing Cures: an introductory handbook of writing in counselling and therapy. Hove, East Sussex: Brunner-Routledge.
[xvi] Wright, J. (2004) The passion of science, the precision of poetry. In: Bolton, G., Howlett, S., Lago, C. and Wright, J.K. (eds.) Writing Cures: an introductory handbook of writing in counselling and therapy. Hove, East Sussex: Brunner-Routledge.
[xvii] Mazza, N. (1999) Poetry Therapy: Interface of the arts and psychology. Boca Raton: CRC Press.
[xviii] Baikie, K.A., and Wilhelm, K. (2005) Emotional and physical health benefits of expressive writing. Advances in Psychiatric Treatment, 11: 338-346.
[xix] Pennebaker, J.W. (1997) Writing about emotional experiences as a therapeutic process. Psychological Science, 8. 162-166.
[xx] Baikie, K.A., and Wilhelm, K. (2005) Emotional and physical health benefits of expressive writing. Advances in Psychiatric Treatment, 11: 338-346.
[xxi] Esterling, B.A., L’Abate, L., Murray, E.J. and Pennebaker, J.W. (1999) Empirical foundations for writing in prevention and psychotherapy: mental and physical health outcomes. Clinical Psychology Review, 19(1): 79-96.
[xxii] Francis, M.E. and Pennebaker, J.W. (1992) Putting stress into words: the impact of writing on physiological, absentee, and self-reported emotional well-being measures. American Journal of Health Promotion, 6(4): 280-287.
[xxiii] Pennebaker, J.W. (1997) Writing about emotional experiences as a therapeutic process. Psychological Science, 8(3): 162.
[xxiv] Daniels, J. and Feltham, C. (2004) Reflective and therapeutic writing in counsellor training. In: Bolton, G., Howlett, S., Lago, C. and Wright, J.K. (eds.) Writing Cures: an introductory handbook of writing in counselling and therapy. Hove, East Sussex: Brunner-Routledge.
[xxv] Smyth, J.M. (1998) Written emotional expression: effect size, outcome types, and moderating variables. Journal of Consulting and Clinical Psychology, 66(1): 174-184.
[xxvi] Lepore, S.J. and Smyth, J.M. (eds) (2002) The Writing Cure: How Expressive Writing Promotes Health and Emotional Well-Being. Washington, DC: American Psychological Association.
[xxvii] Cameron, D. and Nicholls, G. (1998) Expression of stressful experiences through writing: effects of a self-regulation manipulation for pessimists and optimists. Health Psychology, 17(1): 84-92.
[xxviii] Esterling, B.A., L’Abate, L., Murray, E.J. and Pennebaker, J.W. (1999) Empirical foundations for writing in prevention and psychotherapy: mental and physical health outcomes. Clinical Psychology Review, 19(1): 79-96.
[xxix] Ryle, A. (1983) The value of written communication in dynamic psychotherapy. British Journal of Medical Psychology, 56: 361-366.
[xxx] Rasmussen, P.T. and Tomm, K. (1992) Guided letter writing: a long brief therapy method whereby clients carry out their own treatment. Journal of Strategic and Systemic Therapie, 7(4): 1-18.
[xxxi] Adams, K. (1990) Journey to the Self: Twenty-two paths to personal growth. New York: Warner Books.
[xxxii] Adams, K. (1996) Journal writing as a powerful adjunct to therapy. Journal of Poetry Therapy, 10(1): 31-37.
[xxxiii] Brewer, W.D. (1994) Mary Shelly on the therapeutic value of language. Papers on Language and Literature, 30(4): 387-407.
[xxxiv] Gilbert, J. (1995) Clients as poets: reflections on personal writing in the process of psychological change. Clinical Psychology Forum, 75: 3-5.
[xxxv] De Salvo, L. (1999) Writing as a Way of Healing. London: The Women’s Press.
[xxxvi] Bacigalupe, G. (1996) Writing in therapy: a participatory approach. Journal of Family Therapy, 18: 361-373.
[xxxvii] Wright, J.K. (2000) Using writing in counselling women at work. Changes, 18(4): 264-273.
[xxxviii] Lago, C. (2004) ‘When I write, I think’: Personal uses of writing by international students. In: Bolton, G., Howlett, S., Lago, C. and Wright, J.K. (eds.) Writing Cures: an introductory handbook of writing in counselling and therapy. Hove, East Sussex: Brunner-Routledge.
[xxxix] Wright, J.K. (1999) Uses of writing to counter the silence of oppression: counselling women at the University of the South pacific. Pacific Health Dialog, 6(2): 305-310.
[xl] Bass, E. and Davis, L. (1988) The Courage to Heal: a guide for women survivors of child sexual abuse. New York: Harper and Row.
[xli] Bolton, G. (1996b) Every poem breaks a silence that had to be overcome: the therapeutic power of poetry writing. Feminist Review, 62: 118-132.
[xlii] Etherington, K. (2000) Narrative Approaches to Working with Adult Male Survivors of Child Sexual Abuse: The Client’s, the Counsellor’s and the Researcher’s Story. London: Jessica Kingsley.
[xliii] L’Abate, L. (1992) Programmed Writing: A paratherapeutic approach for intervention with individuals, couples and families. Pacific Grove, CA: Brooks/Cole.
[xliv] Riordan, R.J. (1996) Scriptotherapy: therapeutic writing as a counseling adjunct. Journal of Counseling and Development, 74: 263-269.
[xlv] Smyth, J.M. (1998) Written emotional expression: effect size, outcome types, and moderating variables. Journal of Consulting and Clinical Psychology, 66(1): 174-184.
[xlvi] Bolton, G. (1999a) The Therapeutic Potential of Creative Writing – Writing Myself. London: Jessica Kingsley.
[xlvii] Lepore, S.J. and Smyth, J.M. (eds) (2002) The Writing Cure: How expressive writing promotes health and emotional well-being. Washington, DC: American Psychological Association.
[xlviii] Sosin, D.A. (1983) The diary as a transitional object in female adolescent development. Adolescent Psychiatry, 11: 92-103.
[xlix] Atlas, J.A., Smith, P. and Sessoms, L. (1992) Art and poetry in brief therapy of hospitalized adolescents. The Arts in Psychotherapy, 19: 279-283.
[l] Longo, P.J. (1996) If I had my life to live over – Stephanie’s story: a case study in poetry therapy. Journal of Poetry Therapy, 10: 55-67.
[li] Bolton, G. (1998) Writing or pills: therapeutic writing in primary care. In C. Hunt and F. Sampson (eds) The Self on the Page: Theory and Practice of Creative Writing in Personal Development. London: Jessica Kingsley.
[lii] Lepore, S.J. and Smyth, J.M. (eds) (2002) The Writing Cure: How Expressive Writing Promotes Health and Emotional Well-Being. Washington, DC: American Psychological Association.
[liii] “Splitting is very common in people with borderline personality disorder (BPD), and it leads people with BPD to view others and themselves in ‘all or nothing’ terms. For example, a person with BPD may view one family member as always ‘good’ and another as always ‘bad’. Or, a person with BPD may see themselves as ‘good’ one minute, but shift to seeing themselves as all ‘bad’ or even evil the next.” Salters-Pedneault, K. (2008) What is splitting? About.com: Borderline Personality. Available online at: http://bpd.about.com/od/faqs/f/splitting.htm. Accessed: 21st April 2010.
[liv] Gidron, Y., Peri, T., Connolly, J.F., and Shalev, A.Y. (1996) Written disclosure in post-traumatic stress disorder: is it beneficial for the patient? Journal of Nervous and Mental Disease, 184: 505-507.
[lv] Howlett, S. (2004) Writing the link between body and mind: the use of writing with clients suffering from chronic stress-related medical disorders. In: Bolton, G., Howlett, S., Lago, C. and Wright, J.K. (eds.) Writing Cures: an introductory handbook of writing in counselling and therapy. Hove, East Sussex: Brunner-Routledge.