Seminar #2 – Therapeutic Writing

Hello All,

Welcome to our second seminar!

GENERAL BUSINESS:

1) Thank you all for your patience as we work through some glitches between the website and Paypal and are working on them. Be sure when you are trying to access the Seminar pages at What a Shrink Thinks to log in to the site first. If you are still unable to access the Seminar pages please contact the webpage administrator: Shuli, who is kindly helping a technologically-slow-middle-aged-shrink-with-a-little-chemo-brain to set this all up. She can be reached at shuli@shulihallak.com

2) As you can see from the first post –the writing here is not intended to be comprehensive or in anyway definitive on any of the topics we will be exploring. I will be sharing thoughts, ideas, theories, that I have found useful or interesting for your consideration, as I might in the didactic portion of a reading group or a supervision group. None of the ideas I am putting forth – whether they are my own or drawn from other theorists or practitioners – are in any way viewed by me as a “final statement” on any subject. I only hope to expose those who are visiting this space to ideas I find pertinent, provocative or intriguing.

We have beginning practitioners here, students, interested non-clinicians, as well as clinicians who have more training and practice experience than I do. I am hoping that in each post each reader will be able to encounter one new idea or a useful perspective – even if it is a stance or a viewpoint that is rejected or decidedly not integrated into practice. Maybe this is a space we can use to sharpen our swords and keep our tools well oiled. Maybe as I am “thinking out loud” here, it can spur your own thinking even if that sends you in a very different direction than the tack I am taking.

3) Discussion/response: Because I have learned that moderating on-line forums and managing open comments sections can become a very laborious, time-consuming and stressful – you will notice that the usual comments section is “closed.” But I extend an invitation to you all to share your questions, comments and ideas through the “Submit a Question” page (once you can all access it) I will look them over and integrate ideas that emerge there into the beginning of the following post in a Response section.

4) Also: as most of you know from reading the blog – I am interested in a variety of therapeutic models, and see all of these models as having their own internal coherence, that flows out of their unique premises.

Many people have their own preferences and allegiances to various therapeutic schools and models – and reject the premises of other models. I am not really interested in asserting the primacy of one model over another, or defending theoretical models against each other.

There are models I like because they suit me and there are also models that I don’t employ in practice that still interest me. There are models that I know far less about because I’ve had less exposure to them or the language they draw on doesn’t speak to me. Please don’t mistake this as my asserting one model as superior or inferior. Each therapeutic stance and model has its own practitioners and its own client base that feels well served by it.

 

If I am ever speaking about a model that you are less familiar with, want some clarification about, please use the “Question” link I will be glad to suggest further reading or attempt to clarify a confounding construct myself.

 

RESPONSE TO SESSION #1:

There were a few questions and responses to the story I recounted regarding Dr. Mishne’s statement about her traumatized client: “You can’t undo history, the question is: How is she going to live with it?” Some seemed to construe this as a statement on Moshe’s part (or on my part) that trauma that trauma is either untreatable or that her approach was merely present-focused and problem solving. Perhaps other students in the class with me that day heard her that way as well. If you know her work or read her books, it is clear that she was not only deeply invested in trauma and recovery, but extremely astute about the way that past creates a template for our future selves, for good and for ill. I experienced her as saying that the traumatic imprint and the subsequent attempts by trauma survivors to cope with it must always be respected and accepted, maybe even admired by the therapist as attempts to negotiate extraordinary pain. Wounds don’t always hurt as severely as they do immediately after injury, open sores can be treated so that infection clears, sometimes injuries leave permanent damage that can still be born in a meaningful way, and even the best healed wound will leave some scar.

There were a few questions about the Healer/Helper archetype as described by Adolf Guggehbühl-Craig: (let’s call him G-C for the rest of this discussion) G-C was a psychiatrist, a training analyst and eventually the head of the Jungian institute in Zurich (which is interesting as he himself actually never underwent a Jungian analysis of his own) He is famous/infamous for his contrarian stance, and his constant interest in surfacing the unconscious/ulterior motivations that are coupled with roles and behaviors that are commonly considered beneficent. The book I recommended “Power in the Helping Professions” is an exploration of the unconscious dark side/shadow aspects of the helping professions, the ways that the power granted to “Healers” can become contaminated with unconscious and defensive maneuvers on the part of the therapist. He in no way advocates that therapists should intentionally “hoodwink” clients – or avoid our humanity in therapeutic relationships – but he does warn us that our very facility at “self-reflection” and our hyper-developed “psychological mindedness” can be unwittingly and unconsciously employed by therapists to avoid uncomfortable conflicts. The most classic (and extremely common) example of this is when a client confronts a therapist about some failure or impasse that has emerged between them, and in response, the therapist makes a transference interpretation dismissing the confrontation as the client being “merely” caught up in a transference of a problematic figure from childhood. We have all heard such tales, and clicked our tongues but G-C calls on all therapists to examine how they, even in much subtler ways, participate unconsciously in similar actions simply as a result of the powerful position we are placed in as “healers.”

For those interested: He is all about exploring the underbelly– and you can read more about G-G here:

His writings are often quite dated to his era, but I have found them fascinating and worth contemplating.

 

Also: some had questions about the Jungian construct of “archetypes” – a notion that can seem both obvious and mystifying at once: I’ll take a quick pass at defining this construct a little more clearly:

One way of thinking about archetypes is as instinctive patterns and roles that we are programmed to respond to, as a culture or as a species, much like wild geese fly in a ‘V’ that instinctively pulls different members of the flock into different roles, leader, “second lieutenants” mothers, juveniles, those that bring up the rear, etc. Those roles are summoned by the needs of the whole flock, and shift and exchange over the lifetimes of individuals and the flock itself.

These archetypes have both positive and negative faces: Heroic Leader/Tyrant, Healer/Quack, The Great Mother may nurture, smother or devour her offspring. When we consciously manifest one “pole” of these archetypes – in this theoretical model – it means the characteristics of the opposite “pole” have become more unconscious/suppressed. G-C refers to this as “splitting the archetype” and this can be more or less or not at all pathological depending on the severity of the split and the level of ability to consciously consider unconscious aspects.

 

Your comments and questions are very helpful!! I will read them and store them and am keeping lists. 🙂

TODAY’S TOPIC: Therapeutic Writing

Since this is a written space that is evolving here, and you all know me through my writing – I thought the various types of therapeutic writing might be a good idea to explore:

 

Therapeutic journaling:

This is one of the most obvious forms of therapeutic writing, the use of simple journals to track target symptoms and behaviors and to develop insight and increase the client’s locus of control over behavior: Food journals, Sleep Hygiene journals, Financial Spending journals, Substance Abuse/Dependence/Recovery journals – I have used all of these at various times and they are a common feature of most CBT “homework” in some form. Journals can track mood states, link them to events and behaviors that were triggering as well as monitor the efficacy of self-care interventions and many employ a variety of scales to make it easier for clients to monitor their experience. These are usually framed/formatted journals with scales that are available through various CBT sources or you and your client can format your own:

Event: (my sister-in-law visited)

Feeling/Mood: (intense grief and anger)

Symptom/Intensity/Duration: (Panic attack was level 7, duration: 20 min)

Action: (I took a hot bath and filled out this journal)

Outcome: (Anxiety level now at level 3, mild)

 

The purpose of this kind of journaling is to help clients strengthen their “observing ego” by self-reflecting and monitoring, and to develop a greater locus of control over their experience so they no longer feel powerless over behavior stimulating moods states which seem to emerge “out of the blue”, as well as to help clients and therapists together chart and monitor progress. I don’t use such journals that often or for very long – but they can be very helpful for client’s who have little insight into what is driving a behavior they would like to change. I’ve found for some reason, that some clients with real difficulties over-spending & shopping addictions for example are often able to transform their financial lives merely by keeping a spending journal with no other major intervention – and simply by becoming conscious of how they were unconsciously spending money.

 

Trauma Narratives:

 

In work with trauma, – working slowly on a trauma narrative together in the office over many sessions – with a client dictating, (maybe only one additional sentence each week) and the therapist serving as scribe – recording and clarifying and reading back (as the client can tolerate) can be a slow, manageable, regulating contained form of exposure therapy. Writing, the page, the screen, the therapist’s laptop or note pad serves as a container or depository where the content can be “left” and “closed” until the following week, and can help these stories be told without violent affective flooding. Once a “cool” “objective” reporting of events has been recorded, and withstood, and sufficient trust and ego strength has developed in the therapeutic relationship – clients and therapist together may revisit and re-edit the trauma narrative to include “hotter” content such as the subjective and emotional states which are connected to the events. You can read more about how to use trauma narratives here:

I began using such narratives in my very first years of practice – and have used and modified the process of serving as a client’s scribe and witness into various therapeutic relationships with clients with a wide range of issues and levels of functioning. The first case I ever wrote for presentation and publishing was a modified trauma/narrative therapy – which included some creative arts modalities (the client would choose different colored pens for me to write with, and would ask me to insert decoration and drawn symbols, or would decorate the story in the margins himself when he was impatient with my poor artistic skills) and I wrote up the work through a Winnicotian lens.

Dream Work/Active Imagination:

A very common Jungian technique is the use of a dream journal often accompanied by written active imagination exercises. For those less familiar with dream work, it can be very useful – and especially helpful for “thinkers” who over rely on their cognition but who have very hard time making decisions – (who are more cut off from their more intuitive functions) Often clients will say that they “don’t dream” or don’t remember their dreams. I encourage them to keep a pad by their bedside anyway, (some use their phone’s voice memo function to record their dictated dreams) and to press the “sleep” button on their alarms (buzzer only no radio or music alarms). And to ask themselves “where was I?” when they are in the hypnagogic space between sleep and waking and to gather any image, mood, impression or snippet they can summon. Often, fuller, richer dreams emerge over time, and some time can be set aside each session to explore the weeks dreaming.

Often there are characters, entities, phenomenon in the dream that confuse/confound “interpretation” or understanding – and Jung’s “active imagination” writing exercises can often shed light on whatever the dream is sorting through. (Active imagination writing can be done together in session, with therapist as scribe, or by the client alone.)

 

So: let’s say the client has a dream of being robbed at gunpoint by a band of thieves – and is unsettled by the dream: You can ask the client to write out a spontaneous, “imaginary” dialogue with the dream character. (Or even inanimate objects – I’ve had clients dialogue with an image from a dream such as a menacing mist, a powerful tidal wave, or a bus with no driver). The point is not to “write a consciously crafted story” but to play with the symbols – to just “make up some shit”. I recommend that people do this a minimum of concern for punctuation, spelling or grammar and by typing quickly a totally pretend conversation with lowercase letters for themselves, (m: for me) and CAPS LOCK ON FOR THE DREAM FIGURE: (R: FOR ROBBER):

m : why are you following me? what do you want?

R; I WANT WHAT I AM OWED THAT WAS PROMISED TO ME THAT I NEVER RECEIVED.

m : well, what is that? Do you have to threaten me and frighten me to get it?

R; YES. BECAUSE OTHERWISE YOU KEEP US LOCKED WAY UNJUSTLY ALL BECAUSE WE ATTEMPTED TO COLLECT OUR FAIR DUE.

 m : what debt is that? what do you feel you were owed that you never received?

Etc. etc.

 

Some client’s won’t engage in this process at all, but for those that feel engaged by it, it can be extremely valuable.

 

 

Text/Email:

 

Most therapists that I know regularly use email and texting (with proper caveats, waivers, and encryption with respect to privacy and confidentiality laws) to schedule and reschedule clients, or for clients to communicate to them about urgent issues in between sessions, often requiring some supportive communication from the therapist. It has become so ubiquitous that many don’t realize that they are using writing/narrative therapy techniques – Text apps and email accounts often serve as “holding” mechanisms, and depositories so that content is “sent” to the therapist and held by their account, even if the therapist cannot respond until they are clinically available. Often, texts and emails that are sent by therapists to clients, even quite innocuous ones, can serve as transitional objects – read, and re-read, and saved by the client as a soothing object that connects them to the therapist.

 

Certainly many of us have noticed that some clients are more comfortable “using their words” after they have left the office – by sending an email or a text to inform us that something made them uncomfortable in session, that they may have either repressed in your presence, or was too hard for them to say in the moment. Generally, I thank and then encourage clients to bring that content into our next session, and let them know that I will remember it and be sure to bring it up. But even though face-to-face intimacy is the goal in this treatment context, it doesn’t discount that writing – the space, the distance, the chance to collect one’s thoughts, and communicate in writing, was used in service of healthy relatedness.

 

If we expand this kind of interaction: We are then looking at full, formal writing sessions, or “e-sessions” (again, offered only when clinically appropriate and with proper waivers/consents, and confidentiality/privacy precautions) These books by Anthony, Nagel, and Goss are very useful for those who are considering using digital communication and other remote therapy technologies.

They include useful discussions of assessment/appropriateness for various remote/online/digital therapies.

 

I supposed because I was using writing methods in session in the office, for so many – especially for very silent clients who had real difficulties talking, for clients with slower neurocognitive processing speed, and for those who were clearly too fearful, flooded, or became psychologically disorganized with too much face to face conversation – and would sometimes have clients use our session time to write to me while sat quietly nearby, “e-sessions” when they began to emerge as a technological possibility felt like a very natural extension of the work. But I realize that many people wonder what they are and how they work.

 

E-sessions are “asynchronous electronic communication” (as opposed to live chat, instant messaging or other real time forms of digital communication which are synchronous) and again, they can be used in session in the office, or for remote work.

 

Again, Anthony, Nagel and Goss have lots of helpful guidance at how to structure the writing format, how to be a little more assertive with tone with language, or by inserting what I think of as stage directions (playfully) or (rhetorically) or the use of emoticons 😉 I did have one client who experienced “winky” emoticons as a little more evil and trickster-ish rather than merely indicating playful joking, but that was discussed and indentified and adjusted for. How to indicate “listening” through paragraphs that you feel need to be taken in more than actively responded to, by writing “Umm- hmm” or “I’m listening… “I want to keep this in mind” Or “I hear you”

 

Writing therapies are ripe for the client to be able to project a great deal onto the words we type, and tone can become an issue, but frankly, in my experience, not so much more so than it does in the office.

 

I have the client write to me for 45 minutes, and send me the email by a designated, scheduled “appointment” time – during which I will read and respond, in line/in text – creating a kind of retroactive dialogue.

 

Client “A” who kept a journal of their own, who did sometimes write to me after sessions, and with whom I had used therapeutic writing techniques through silent sessions, had worked on trauma narratives and imaginal unsent letters to characters from “A’s” past and also used e-sessions as “extra” sessions during periods of crises when “A” was unable to travel to the office more than once a week. “A” wanted to write a piece collaboratively with me, and much of this post emerged over “e-sessions” and takes that format.

 

I have done writing sessions with clients who I have only encountered remotely, Usually this has been with clients who have a facility with writing, who live in areas where in office psychotherapy is unavailable to them – extremely rural areas, or ex-pats/immigrants who are residing in a country where there is no culturally compatible form of psychotherapy, or it is non-existent. But those have been rare occasions and are the exceptions to the rule, and generally they are augmented by video conferencing sessions.

 

I’ve found that what is lost in vivo – visual cues, tone of voice is often compensated for by word choice, by reviewing how topics appear on the page in order, by seeing how thoughts are laid out, by noticing interesting words or images, which repeat, or pop-out or seem anomalous in some way. – As well as typos and sentence fragments – (I saw that in Seminar #1 I had unconsciously typed “parents” instead of “patients” for example when I was transcribing a quote! Grist for the mill!) although autocorrect and autosuggest can make typos less reliable as “slips.”

And all this data, when you have learned to read closely, are often as revealing as a shaking foot or a blush or tension in someone’s speaking voice.

 

Personal Journals

 

And finally, like prescribing mindfulness techniques, I find that prescribing free-written privately kept journaling – that are never read directly out loud in session, that are for the client to keep for themselves can be a powerful method for certain clients who need to build up their self-observation deck, to deposit flooded content, or simply practice listening to themselves, developing self-knowledge and self-reflection. Sometimes providing a “blank book” with a pen become a meaningful transitional object for clients to hold onto in order to feel connected to the therapy in between sessions, or at time of termination.

 

Next seminar will be mid-June. I will announce on the FB page, and hopefully our technical problems will be corrected by then!