Mastery or mystery? Therapeutic writing: A review of the literature

Write and Let Go: An Online Writing Program for University Students

Background

There are a plethora of studies on expressive writing and positive writing interventions, but few have addressed the combination of both paradigms. Additionally, research on the role of ambivalence toward change in the context of writing-based interventions is lacking. Ambivalence toward change is a natural movement of approaching and avoiding change that may occur in various situations. In psychotherapy, its resolution is associated with successful outcomes.

Aim

This study tested the efficacy of a combination of expressive and positive writing paradigms in an internet-based intervention to improve university students' mental health. Additionally, focusing participants on a current, unresolved problem allowed us to explore the possible role of ambivalence toward change as a mediator of the intervention's results.

Methods

We recruited 172 participants who were randomly divided into experimental (n = 85) and control (n = 87) groups. The intervention consisted of the identification of a current problem and four writing tasks on consecutive days. Assessment was conducted at baseline and posttest in both groups and at follow-up in the experimental group. Participants in the experimental condition were also assessed after each task. Measures of anxiety, depression, rumination, ambivalence toward change, distress, and wellbeing (optimism, affect, and satisfaction with life) were collected.

Results

Multivariate analysis of variance (MANOVA) showed that participants in the experimental group had a significant decrease from baseline to posttest in ambivalence toward change and rumination when compared with the control group. These results were maintained at follow-up. No differences were found in the remaining measures. Within the experimental group, ambivalence toward change, rumination, and distress significantly decreased throughout the intervention and the exploratory mediation analysis indicated that ambivalence toward change partially mediated the improvements in rumination and distress.

Discussion

Considering different perspectives about a current problem and using a combination of expressive and positive writing fostered the reduction of ambivalence toward change and rumination. Ambivalence toward change reduction after the second writing task may have created optimal conditions for the subsequent decrease in rumination and distress. Future studies should replicate this finding and dismantle the components that are more adequate in changing these variables.

I Let Depression and Anxiety Drown Me: Identifying Factors Associated with Resilience Based on Journaling using Machine Learning and Thematic Analysis

Over the years, there has been a global increase in the use of technology to deliver interventions for health and wellness, such as improving peoples mental health and resilience. An example of such technology is the Q-Life app which aims to improve peoples resilience to stress and adverse life events through various coping mechanisms, including journaling. Using a combination of sentiment and thematic analysis, this paper presents the results of analyzing 6023 journal entries from 755 users. We uncover both positive and negative factors that are associated with resilience. First, we apply two lexicon-based and eight machine learning (ML) techniques to classify journal entries into positive or negative sentiment polarity, and then compare the performance of these classifiers to determine the best performing classifier overall. Our results show that Support Vector Machine (SVM) is the best classifier overall, outperforming other ML classifiers and lexicon-based classifiers with a high F1-score of 89.7%. Second, we conduct thematic analysis of negative and positive journal entries to identify themes representing factors associated with resilience either negatively or positively, and to determine various coping mechanisms. Our findings reveal 14 negative themes such as stress, worry, loneliness, lack of motivation, sickness, relationship issues, as well as depression and anxiety. Also, 13 positive themes emerged including self-efficacy, gratitude, socialization, progression, relaxation, and physical activity. Seven (7) coping mechanisms are also identified including time management, quality sleep, and mindfulness. Finally, we reflect on our findings and suggest technological interventions that address the negative factors to promote resilience.

Writing Technique Across Psychotherapies-From Traditional Expressive Writing to New Positive Psychology Interventions: A Narrative Review

Writing Therapy (WT) is defined as a process of investigation about personal thoughts and feelings using the act of writing as an instrument, with the aim of promoting self-healing and personal growth. WT has been integrated in specific psychotherapies with the aim of treating specific mental disorders (PTSD, depression, etc.). More recently, WT has been included in several Positive Interventions (PI) as a useful tool to promote psychological well-being. This narrative review was conducted by searching on scientific databases and analyzing essential studies, academic books and journal articles where writing therapy was applied. The aim of this review is to describe and summarize the use of WT across various psychotherapies, from the traditional applications as expressive writing, or guided autobiography, to the phenomenological-existential approach (Logotherapy) and, more recently, to the use of WT within Acceptance and Commitment Therapy (ACT). Finally, the novel applications of writing techniques from a positive psychology perspective will be analyzed. Accordingly, the applications of WT for promoting forgiveness, gratitude, wisdom and other positive dimensions will be illustrated. The results of this review show that WT yield therapeutic effects on symptoms and distress, but it also promotes psychological well-being. The use of writing can be a standalone treatment or it can be easily integrated as supplement in other therapeutic approaches. This review might help clinician and counsellors to apply the simple instrument of writing to promote insight, healing and well-being in clients, according to their specific clinical needs and therapeutic goals.

Study protocol of a randomised controlled trial on SISU, a software agent providing a brief self-help intervention for adults with low psychological well-being

INTRODUCTION

Only a minority of people living with mental health problems are getting professional help. As digitalisation moves on, the possibility of providing internet/mobile-based interventions (IMIs) arises. One type of IMIs are fully automated conversational software agents (chatbots). Software agents are computer programs that can hold conversations with a human by mimicking a human conversational style. Software agents could deliver low-threshold and cost-effective interventions aiming at promoting psychological well-being in a large number of individuals. The aim of this trial is to evaluate the clinical effectiveness and acceptance of the brief software agent-based IMI SISU in comparison with a waitlist control group.

METHODS AND ANALYSIS

Within a two-group randomised controlled trial, a total of 120 adult participants living with low well-being (Well-being Scale/WHO-5) will be recruited in Germany, Austria and Switzerland. SISU is based on therapeutic writing and acceptance and commitment therapy-based principles. The brief intervention consists of three modules. Participants work through the intervention on 3 consecutive days. Assessment takes place before (t1), during (t2) and after (t3) the interaction with SISU, as well as 4 weeks after randomisation (t4). Primary outcome is psychological well-being (WHO-5). Secondary outcomes are emotional well-being (Flourishing Scale), psychological flexibility (Acceptance and Action Questionnaire-II), quality of life (Assessment of Quality of Life -8D), satisfaction with the intervention (Client Satisfaction Questionnaire-8) and side effects (Inventory for the assessment of negative effectsof psychotherapy). Examined mediators and moderators are sociodemographic variables, personality (Big Five Inventory-10), emotion regulation (Emotion Regulation Questionnaire), alexithymia (Toronto Alexithymia Scale-20), centrality of events (Centrality of Events Scale), treatment expectancies (Credibility Expectancy Questionnaire) and technology alliance (Inventory of Technology Alliance-Online Therapy). Data analysis will be based on intention-to-treat principles. SISU guides participants through a 3-day intervention.

ETHICS AND DISSEMINATION

This trial has been approved by the ethics committee of the Ulm University (No. 448/18, 18.02.2019). Results will be submitted for publication in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION

The trial is registered at the WHO International Clinical Trials Registry Platform via the German Clinical Trials Register (DRKS): DRKS00016799 (date of registration: 25 April 2019). In case of important protocol modifications, trial registration will be updated. This is protocol version number 1.

Comparing life review writing with active control groups: Results of a feasibility study

INTRODUCTION

Life review writing can be used to improve depressive symptoms in well older adults, but it is unclear whether the reminiscing, writing, or socialising is associated with the improvements. This study assessed the feasibility of a controlled trial comparing life review writing with two active control groups designed to isolate the acts of (a) engaging in a meaningful leisure activity and (b) socialising.

METHODS

Twenty-four participants from a 100-bed assisted living facility were enrolled in the study. Participants ranged in age from 70 to 98 years (M = 83.9, SD = 7.6). Eight 1-hour weekly sessions were held, with participants assigned to one of three groups: (a) life review writing, (b) painting, or (c) coffee from around the world. At baseline, participants completed a demographic and health questionnaire, the Mini-Cog, and the Geriatric Depression Scale Short Form (GDS-15). The GDS-15 was administered again at weeks 4 and 8, along with the health questionnaire at post-test.

RESULTS

Nearly 25% (N = 24) of the facility's residents attended at least one session, with an average attendance rate of 66.4%, or 5.3 sessions. However, to achieve this participation rate, our original plan to employ random assignment had to be abandoned. The groups were a partial success insofar as we successfully isolated engaging in a meaningful activity in the painting group, but the writing group engaged in less reminiscing than hoped. At post-test, seven participants reported health, mood, and social life benefits. GDS-15 scores fluctuated over time, with no significant improvement from pre- to post-test.

CONCLUSION

The residents' low willingness to be randomised creates a serious selection bias, but randomising volunteers into different activities runs counter to client-centred therapy. To scrutinise the mechanisms of change of life review writing, we recommend comparing two writing groups: one that reminisces and one that does not.

Exploring Mental Health Issues through the Use of Blogs: A Scoping Review of the Research Evidence

The aim of this scoping review of the available research evidence was to explore the experiences and perceptions of people with mental health difficulties through the use of blogs. A search of relevant electronic databases was undertaken from January 2009 to February 2019. Selected studies included people who blog about their mental health difficulties online. The PRISMA system was used to present the results of the searches. Following the application of specific inclusion and exclusion criteria, the final number of included studies was eleven. Following data analysis, the subordinate categories in the public category were moderation, confidentiality and boundaries. The subordinate categories in the private sphere included catharsis, enhanced coping strategies and social connectedness. The implications for mental health practice developments and research, are presented and discussed.

Emotional disclosure as a therapeutic intervention in palliative care: a scoping review protocol

INTRODUCTION

Emotional disclosure (ED) is a term used to describe the therapeutic expression of emotion. ED underlies a variety of therapies aimed at improving well-being for various populations, including people with palliative-stage disease and their family carers. Systematic reviews of ED-based psychotherapy have largely focused on expressive writing as a way of generating ED. However, heterogeneity in intervention format and outcome measures has made it difficult to analyse efficacy. There is also debate about the mechanisms proposed to explain the potential effects of ED.We present a scoping review protocol to develop a taxonomy of ED-based interventions to identify and categorise the spectrum of interventions that could be classified under the umbrella term of 'emotional disclosure' in the palliative care setting. By mapping these to associated treatment objectives, outcome measures and explanatory frameworks, the review will inform future efforts to design and evaluate ED-based therapies in this population.

METHODS AND ANALYSIS

The review will be guided by Arksey and O'Malley's five-stage scoping review framework and Levac's extension. The following electronic databases will be searched from database inception: CENTRAL, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Web of Science and MEDLINE. We will include peer-reviewed studies and reviews. We will also check grey literature, including clinical trial registers, conference proceedings and reference lists, as well as contacting researchers. Articles will be screened by at least two independent reviewers and data charted using an extraction form developed for this review. Results will be analysed thematically to create a taxonomy of interventions, outcome measures and theoretical frameworks.

ETHICS AND DISSEMINATION

This review does not require ethical approval as it is a secondary analysis of pre-existing, published data. The results will inform future research in the development of ED-based interventions and evaluation of their efficacy in the palliative care setting. We will disseminate findings through peer-reviewed journals.

"I´m the one who has written this": reciprocity in writing courses for older adults in Norway

Purpose: The aim of this article is to explore, theoretically and empirically, the reciprocity of care afforded by writing courses as community interventions for older adults.

Methods: We narratively analyzed 209 excerpts of the anthology “I´m the one who has written this” written by teachers and participants of courses organized by the Church City Mission in Norway.

Results: The reciprocity that appeared in the writing courses is grounded in the sense of vulnerability that both teachers and participants embraced, and that is experienced in three main relational movements that these writing courses convey: self-exploration, otherness and togetherness. In addition, the data suggests that these courses promote affective processing and existential meaning-making, motivation, as well as improvements of memory and attention. However, more research is needed to confirm these preliminary findings, and their possible effects in older adults with and without symptoms of dementia.

Conclusion: Even though these writing courses for older adults are not explicitly therapeutic, they can have therapeutic effects, given the reciprocity afforded in these cultural community interventions. A theoretical exploration upon reciprocity in eldercare is hereby provided. These findings could shape improvements in aging and health care policies that are person-centered and focus on reciprocity.

Dear Breath: using story structure to understand the value of letter writing for those living with breathlessness - a qualitative study

Background: Despite the prevalence of dyspnoea (the pathological term for breathlessness) amongst the general population and the diagnostic importance of dyspnoea for respiratory illness, public awareness of dyspnoea is poor with an estimated two million people with undiagnosed Chronic Obstructive Pulmonary Disorder in the UK. We explore whether therapeutic letter writing is a valuable arts health approach for those living with breathlessness. Methods: Eighty (80) participants took part in 10 workshops held in community-based settings. The overall approach was qualitative. We analysed the data thematically. Results: Informed by theories of story structure, our analysis explores letters written to the breath in terms of there being a protagonist, antagonist, a process of recognition and reconciliation. Conclusions: Writing a letter to the breath facilitates new ways of relating to breathlessness. Letters create a personal narrative and workshops create a public story. Further research should explore whether therapeutic letter writing can support communication about breathlessness with clinicians.

The impact of an emotionally expressive writing intervention on eating pathology in female students

Introduction: Previous research demonstrating emotional influences on eating and weight suggest that emotionally expressive writing may have a significant impact on reducing risk of eating pathology. This study examined the effects of writing about Intensely Positive Experiences on weight and disordered eating during a naturalistic stressor.

Method: Seventy-one female students completed an expressive or a control writing task before a period of exams. Both groups were compared on BMI (kg/m²) and the Eating Disorder Examination – Questionnaire (EDE-Q) before the writing task and at 8-week follow-up. A number of secondary analyses were also examined (to identify potential mediators) including measures of attachment, social rank, self-criticism and self-reassurance, stress and mood.

Results: There was a significant effect of intervention on changes in the subscales of the EDE-Q (p = .03). Specifically, expressive writers significantly reduced their dietary restraint while those in the control group did not. There was no significant effect of the intervention on changes in BMI or the other subscales of the EDE-Q (Eating, Weight and Shape Concern). There was also no effect of writing on any of the potential mediators in the secondary analyses.

Discussion: Emotionally expressive writing may reduce the risk of dietary restraint in women but these findings should be accepted with caution. It is a simple and light touch intervention that has the potential to be widely applied. However, it remains for future research to replicate these results and to identify the mechanisms of action.

The Impact of Participating in a Poetry Workshop

Poetry writing is a creative activity and, as such, may contribute to intervention. The aim of this study was to explore the impact of poetry writing on individuals who had experienced mental health problems in the past. A qualitative approach, that of grounded theory, was used, including observations of a poetry writing group and in-depth semi-structured interviews with two group participants who had a previous history of mental health problems.

The main categories that emerged during data analysis were creation, communication, connection and awareness; these categories were unified by a central concept of personal meaning. The findings suggest that poetry writing creates and communicates meaning. In addition, internal connection (with self) and external connection (with others) may be facilitated through the communication of poetry. Communication and experiences of connection can lead to a greater awareness of self and others. Personal meaning is central to human life in symbolisation processes, which contribute to identity building.

The positive and negative impacts on mental health through the writing of poetry and participating in a group were identified. This is a small study and the findings are valid only in the immediate context of the study, but it provides a basis for further research.

The weight loss blogosphere: an online survey of weight loss bloggers

Blogging is a form of online journaling that has been increasingly used to document an attempt in weight loss. Despite the prevalence of weight loss bloggers, few studies have examined this population. We examined characteristics of weight loss bloggers and their blogs, including blogging habits, reasons for blogging, like and dislikes of blogging, and associations between blogging activity and weight loss. Participants (N = 194, 92.3 % female, mean age = 35) were recruited from Twitter and Facebook to complete an online survey. Participants reported an average weight loss of 42.3 pounds since starting to blog about their weight loss attempt. Blogging duration significantly predicted greater weight loss during blogging (β = -3.65, t(185) = -2.97, p = .003). Findings suggest that bloggers are generally successful with their weight loss attempt. Future research should explore what determines weight loss success/failure in bloggers and whether individuals desiring to lose weight would benefit from blogging.

Online Counseling

This article reviews the online-counseling literature with an emphasis on current applications and considerations for future research. It focuses on primary themes of counseling psychology including the history of process-outcome research and multiculturalism. It explores current gaps in the literature from a counseling psychology framework, including the field’s focus on normal and developmental challenges and tasks, client strength and resilience, education and career development, prevention and wellness, and multiculturalism. In general, current evidence indicates that online counseling may be a viable service option for some clients, especially those who are typically isolated; however, questions remain regarding the effectiveness and appropriateness of online counseling.

Ideological meaning making after the loss of a child: the case of Israeli bereaved parents

The study provides a view of ideological meaning-making processes of 10 Israelis who lost a child examining the parents' perspectives and written public documents. The texts and interviews were analyzed using Gadamer's hermeneutic philosophy. Findings indicate that bereaved parents construct conflicting ideologically oriented viewpoints: doubting and affirming the Zionist ideology; ascribing sense and senselessness to the loss; and joining the ethos but keeping personal meanings. Our conclusion is consistent with theorists who reject the notion that the human narrative should be coherently unified. We point to potential links between relational dialectics and meaning-making theory and outline implications for practice.

Effect of life review writing on depressive symptoms in older adults: a randomized controlled trial

OBJECTIVE

We examined the effects of engaging in the occupation-based intervention of life review through writing on expressed depressive symptoms as measured with the Geriatric Depression Scale in older adults residing in senior residences.

METHOD

The study design was a randomized controlled trial that took place in four senior residences in New York City. Forty-five participants (23 treatment, 22 wait-list control) ≥ 65 yr old participated in the 8-wk, once-weekly autobiographical writing workshop, Share Your Life Story (Sierpina, 2002).

RESULTS

Depressive symptoms were significantly less prevalent for the treatment group than for the control group after the 8-wk life review program (repeated-measures analysis of variance p = .03).

CONCLUSION

The results suggest that the Share Your Life Story writing workshop is an effective occupation-based intervention for occupational therapists to use with older adults who reside in senior residences.

Creative writing in recovery from severe mental illness

There is evidence that creative writing forms an important part of the recovery experience of people affected by severe mental illness. In this paper, we consider theoretical models that explain how creative writing might contribute to recovery, and we discuss the potential for creative writing in psychosocial rehabilitation. We argue that the rehabilitation benefits of creative writing might be optimized through focus on process and technique in writing, rather than content, and that consequently, the involvement of professional writers might be important. We describe a pilot workshop that deployed these principles and was well-received by participants. Finally, we make recommendations regarding the role of creative writing in psychosocial rehabilitation for people recovering from severe mental illness and suggest that the development of an evidence base regarding the effectiveness of creative writing is a priority.

What I never wanted to tell you: therapeutic letter writing in cultural context

Therapeutic letter writing has been viewed by psychologists as a powerful form of creative writing in health care settings. I explore the cultural contexts that have aided its popularization to shed fresh light on debates about its psychological function and efficacy. I draw on the sociologist Frank Furedi's analysis of 'therapy culture' to argue that contemporary ideologies of the vulnerable self have stimulated this practice, particularly in the form of letters written not-to-be-sent. I conclude by considering models of developmental letter writing that attempt to challenge these ideologies, including narrative therapists' provocative method of corresponding with clients.

Blogging as 'therapy'? Exploring personal technologies for smoking cessation

This article presents some early, design-oriented research findings from a study that introduced mobile blogging technologies to four people who wished to make a health-related life change--giving up smoking. We wanted to establish the nature of the relationship between blogging and quitting smoking (if any), inspired by some earlier work in the domain showing that social technologies may help with the quit process. We present an account of three participants, documenting details of how blogging technologies fitted into their (changing) lives and examples of digital content they produced. We describe, using examples from participant blogs, instances of self-expression, replacement and self-awareness. We suggest, despite all participants failing in their quit attempts, that there are possible provisional, therapeutic characteristics to such social technologies. Finally, we suggest this therapeutic process can be understood better through a concept of personal translucence.

Beyond expressive writing: evolving models of developmental creative writing

Pennebaker's expressive writing paradigm has helped to introduce the benefits of writing to health care. However, research in expressive writing has been largely dominated by an experimental and quantitative approach that does not take into account critical methodologies and approaches in health psychology, the increasingly complex ways in which creative writing is now being used in health care settings or recent research in the broader field of creative writing and personal development, health and well-being (developmental creative writing). This article contrasts expressive writing theories and methodologies with those evolving in the relatively new field of developmental creative writing. It investigates a number of theoretical and methodological problems with the expressive writing model and argues for a more critical approach to future research.

Getting better byte by byte: a pilot randomised controlled trial of email therapy for bulimia nervosa and binge eating disorder

One hundred and ten people in an university population responded to emailed eating disorder questionnaires. Ninty-seven fulfilling criteria for eating disorders (bulimia nervosa (BN), binge eating disorder (BED), EDNOS) were randomised to therapist administered email bulimia therapy (eBT), unsupported Self directed writing (SDW) or Waiting list control (WLC). Measures were repeated at 3 months. Diagnosis, Beck depression inventory (BDI) and Bulimia investigatory test (BITE) scores were recorded. Follow-up rate was 63% and results must be interpreted cautiously. However significantly fewer participants who had received eBT or SDW fulfilled criteria for eating disorders at follow up compared to WLC. There was no significant difference between eBT and SDW in the analysis of variance (ANOVA), although in separate analyses, eBT was significantly superior to WLC (p < 0.02) and the difference for SDW approached significance (p = 0.06). BDI and BITE scores showed no significant change. For eBT participants there was a significant positive correlation between words written and improvement in BITE severity score. BN, BED and EDNOS can be treated via email.

In the eyes of the beholder: exploring psychologists' attitudes towards and use of e-therapy in Norway

Norwegian psychologists' use of and attitudes towards e-media such as email and mobile text messaging in interaction with clients (e-therapy) were explored. A two-dimensional scale for measuring attitudes towards e-therapy was developed. A total of 1040 (23%) members of the psychologist association responded to a questionnaire June 2003. Of these, 45% had used e-media in interaction with clients. The mean reported attitude towards e-therapy was neutral, with only 3% of the psychologists feeling that use of e-media between client and therapist is unacceptable. Having a psychodynamic theoretical stance was related to attitudes towards e-therapy. Positive attitude was related to clinical use of email and Short Messages Service (SMS). It appears likely that e-therapy will become more common, and that therapist's attitudes are related to such use.

Writing characteristics of suicidal people on the Internet: a psychological investigation of emerging social environments

Three studies were carried out to investigate the writings of suicidal people on the Internet, hypothesizing consistent findings to equivalent research of offline writing. In Study 1, suicidal persons' (n = 34) attributions as the cause of their condition, as expressed in their free online writing, were compared to those of emotionally distressed, nonsuicidal (n = 16) and to nondistressed (n = 15) individuals. Results showed that suicidal persons have significantly more stable and global attributions than do the other groups. In Study 2, expressions of self-focus in online written messages were compared among suicidal, two levels of nonsuicidal but distressed, and nondistressed individuals (200 messages in each group). With the use of various expressions of self-focus, findings showed that suicidal people were distinctively self-focused in their writing, unlike their counterparts. In Study 3, psychologically relevant themes in the online writing of suicidal (n = 39) and highly distressed, nonsuicidal persons (n = 24) were compared. Results revealed that the former expressed significantly more unbearable psychological pain and cognitive constriction than did the latter. The findings of the three studies are consistent with those found in examinations of offline writing. The research has important implications for the use of online environments for psychological research and means for assessment, as well as for understanding suicidality.