Writing as therapy

Adams, Kathleen

At 4:00 on Monday afternoon, the women arrive for writing group. Ruth, at 72, is the senior member both in chronology and experience. She has taught her own journal classes since her retirement and has participated in this group for nearly 4 years, during which time she has confronted her fears of dying, declared herself emancipated from the need to please others, discovered herself as a poet, and grown into her role as a wise elder.

Jean, 41, grieves the loss of a 23-year marriage and writes the stories of her hopes and dreams as a woman reborn at midlife. Eva, 63, is sheltered in the support of a caring community as she embraces retirement and heals from injury. Catherine, 49, plunges deeply into her own uncharted waters as she explores life after breast cancer. Susan, 57, seeks balance for the demands and pressures of corporate management.

For 2 hours on Monday afternoon, these women write their lives. With the glue of ink, guidance, permission, and witnessing, these women craft the images of their own emerging selves. In the silence of pages and the privacy of their own minds, they hear their internal voices.

"Something happens when I write that doesn't happen when I only think or feel or talk," says Ruth. "I come home to myself. I listen to myself with the same care and attention I would give a loved one."

The simple, yet powerfully effective practice of writing thoughts and feelings in a notebook or on a computer-keeping a journal-is a potent agent for change, growth, and healing. Journal writing offers a nonmedicated, client-centered, holistic, self-regulated approach to life management. The act of self-charting leads to the skill of self-reflection. This skill, when carefully applied, leads to the process of integration and ultimately to the art of graceful change. Healing happens.

But as a client once wrote, "A new pen and notebook do not a journal make." In this article I will discuss ways that we, as clinicians, can offer journal writing as a purposeful and intentional psychospiritual process-a therapeutic act in and of itself.

JOURNAL WRITING IS...

I frequently open clinical training in journal therapy by asking participants (who typically have experiential knowledge but no formal training in this work) to complete two sentence stems:

Journal writing is . . .

When my clients and patients write journals. . .

Listen to the collective responses from a recent group of substance abuse counselors, therapists in private practice, and medical social workers:

Journal writing is . . .

. . . extremely helpful.

. . . essential.

. . . writing down thoughts and feelings in a way that leads somewhere.

. . . valuable to deal with difficult material.

. . . an important adjunct to therapy.

. . . quite helpful.

. . . effective in facilitating change.

. . . focusing and revealing.

. . . sometimes helpful in providing a structured way to express feelings.

. . . helpful in organization of feelings, thoughts, process.

When my clients and patients write journals. . .

. . . they often make faster progress.

. . . they sometimes use journals to remember what they want to talk about.

. . . they are less anxious.

. . . they progress more quickly.

. . . they sometimes feel worse.

. . . they are better able to organize and structure their experiences.

. . . they seem to understand their life issues differently.

. . they use the time to look inward.

. . . they express thoughts and feelings they were unaware of.

What can we discern from this collage of responses drawn from direct observation and experience of those who sit with clients and their journals? Simply and elegantly this: The combination of therapy and writing helps bring out an individual's natural capacities for healing and change. When writing is used either as an adjunct to the therapeutic process or as a therapeutic process in and of itself, it is possible to cathart, process, reflect, and integrate.

Journaling helps me process life. First, it forces me to slow down and pay attention to myself. I have a tendency to do, and overlook the need for being. Sometimes the writing helps me clarify an issue because as I reread, I often discover issues and thoughts that have been overlooked. Journaling allows me to share my innermost thoughts and feelings. (Personal correspondence from A. Cline, May 1998)

A BRIEF HISTORY OF JOURNAL THERAPY

A discussion of the history of journal therapy must begin with analytically trained psychologist Ira Progoff, whose intensive journal method has become the standard by which all therapeutically oriented journal modalities are measured. The intensive journal, first offered to the public in 1966, has its foundation in Progoff's work a decade earlier with a radical model of "holistic depth psychology," which he theorized as "the very opposite of an analytic, segmental approach to man" (Progoff, 1959) in its goals and procedures. Progoff envisioned a therapeutic style that "deliberately refrains from dissecting man and marking him off into compartments" but, rather, worked to understand an individual as a whole being, constantly in the process of growth:

The role and purpose of a holistic depth psychology are to describe the possibilities hidden in the depths of man. to ascertain the processes by which they unfold, and to devise practical procedures with which to expedite and enlarge the natural growth of personality. (Progoff, 1959, p. 4)

The intensive journal was developed as just such a "practical procedure" that would offer individual seekers access to their own depths. In 1957, Progoff began using a journal as an adjunct to psychotherapy in his private practice. After years of refining his "psychological notebooks" (Progoff, 1965) with processes, questions, and styles that would promote therapeutic outcomes, he evolved into the idea of a journal with sections structured in such a way that "the very process of working within the journal would have the effect of . . . evoking the content of a person's life" (Progoff, 1975, p. 31).

Progoff was adamant in his intention that the intensive journal be both self-sustaining and a replacement for authoritarianism in the therapeutic process. His clear desire was that the "authority side of psychotherapy" (Progoff, 1975) be replaced with a method of working within oneself that would be self-contained and autonomous and would, therefore, sustain the integrity of the individual:

(T)he joumal needed to be developed into a format that would enable it to contain and carry all the potent psychic material, all the energies and ideas and feelings, that would be set loose when a person was freed from the directiveness of a therapist's authority. (Progoff, 1975, pp. 28-29)

The major criticisms of the intensive journal, paradoxically, involve perceptions by users that the method is difficult to sustain outside of a directed setting, and that its inherent structure is restrictive and authoritarian. Unfortunately, the brilliance of the intensive journal method is obscured by its logistical shortcomings, because those who are successful in mastering its complexity are in agreement that the processes and practices do invite the "knowledge beyond understanding . . . that comes to us at depth" (Progoff, 1975). Nonetheless, Progoff's vision was realized in his lifetime through the combination of his own body of work and those of humanistically and transpersonally oriented journal therapists such as Baldwin (1977,1990), Rainer (1978,1997), Capacchione (1979, 1988), Metzger (1992) and Adams (1990, 1994, 1998b).

Christina Baldwin is best known for defining the journal as sourcebook for spiritual quest. Tristine Rainer was mentored by the great diarist Anais Nin. Her work carries Nin's legacy forward to new generations of journalkeepers and is a comprehensive guide for both creative and reflective diarists and autobiographers. Lucia Capacchione is an art therapist whose signature work combines the Progoff technique of dialogue with nondominant-hand writing and drawing. Deena Metzger's brilliant work with creativity and story invites exploration into other-worldly realms of archetype, mythology, and imagination. My own body of work focuses on ways to offer journal writing as a therapeutic act and strives to make the healing art of journal writing accessible to anyone who desires self-directed change.

In the 1980s many public school systems began formally using journals in English classes and across the curricula. These journals, often called "dialogue"or "response" journals, offered a way for students to develop independent thinking skills and gave teachers a method for responding with individual feedback. Although the intention for classroom journals was educational rather than therapeutic, teachers and guidance counselors noticed that a simple assignment to reflect on a specified subject or academic problem often revealed important information about the students' emotional lives. Students often reported a relief of pressure and tension when they wrote down troubling events or confusing thoughts and feelings.

DEFINITION OF TERMS

Journal therapy describes the purposeful and intentional use of cathartic, reflective, process or integrative writing to further therapeutic goals.

Journal and diary are used interchangeably. Journal is considered to be more internal and reflective than diary, which carries a sense of a day-to-day recording of events and activities.

Therapeutic writing describes the "simultaneous participation in and observation of life and its journeys, traumas, lessons, quests, disappointments, joys and foibles" (Adams, 1996a) in a way that leads to understanding, insight, acceptance, and growth.

Cathartic writing focuses on expression of high affective states and offers a container for the externalization of feelings into language and form.

Reflective writing involves the skill of self-observation and awareness of the interconnectedness of seemingly disparate joinings, such as mind/body, internal/external, thoughts/feelings, expectations/results.

Process writing is characterized by fluidity of thought, leading to spontaneous and organic insights and "ahas of recognition" (Taylor, 1992) as material from the unconscious mind or the collective unconscious is revealed and brought to conscious awareness.

Integrative writing is the process of giving voice to the inherent wisdom of the emerging self and in so doing synthesizing guidance, assimilating learning and embracing change.

The journal toolbox (Adams, 1990, 1994), given in the Appendix, describes the various writing techniques, or tools, that are used to craft journal therapy interventions.

The journal ladder, also known as the developmental continuum of journal therapy (Adams 1998b), offers a way to tailor a journal therapy intervention to the client, situation, and presenting problem in a way that enhances the likelihood of therapeutic outcome. It is described and pictured at Figure 1.

Structure, pacing and containment are three vital journal tools that form the rungs of the journal ladder. Structure describes the internal or inherent foundation, form, orderliness, or sequencing of tasks available in a given journal technique. Pacing describes the rhythm, movement and timing of a technique. Containment describes the boundaries and limits of a technique. Suggestions for clients' use of structure, pacing, and containment are found in Table 1.

THE JOURNAL LADDER

The developmental continuum of journal therapy is a 10step ladder (Figure 1) that starts with the most highly structured, highly contained, highly paced journal technique (Sentence Stems) and gradually builds in fluidity and openness. The continuum ends with Free Writing, which is where most other methodologies begin. (Adams, 1998b)

When it is used purposefully and intentionally, Free Writing can be a highly effective technique that offers clarity, insight and intuitive connection. But as a default technique it can feel uncontrolled and risky, like a colt without a bridle or a free-fall with a dubious parachute. At other times it can feel like a dog leashed to a clothesline, going nowhere in tight, unsatisfying circles. (Adams, 1994)

With the foundation of structure, pacing and containment in place, therapeutic writing becomes a matter of matching a mood, issue, or desired outcome with a journal intervention that predicts success. For example, highly charged emotional states are served by techniques that promote catharsis and do so in ways that are appropriately paced and safely boundaried. The journal tools of Clustering, 5-Minute Sprints, and Unsent Letters are all good choices for cathartic writing. The best choice among them will come from the specifics of the individual's situation.

An individual who has difficulty expressing with words or writing may benefit from catharting through Clustering, which does not rely on orderly sequencing or grammatical construct and actually rewards those whose thought processes are scattered. An individual who ruminates, or who holds explosive or implosive emotional energy, can be guided to release in small, intense bursts through a 5-Minute Sprint. When the source of the issue is relational, Unsent Letters are an excellent way to clarify position and effect behavioral rehearsal through metaphoric communication.

ASSESSING PREDICTORS OF SUCCESS

Journal therapy can be used effectively with clients at most developmental skill levels and with a broad variety of therapeutic issues and tasks. As with any effective therapy, the journal intervention has to be matched to the client's ability to master it (Adams 1998b). Lower-functioning clients will be served by the structured, concrete journals tasks at the bottom of the ladder, whereas higher functioning clients can effectively use the more insight-oriented techniques.

One of the therapist's first tasks is to assess whether an individual client is a likely candidate for journal therapy. No matter how inexperienced or aversive the client, if only one of the following predictors of success is strongly in place, journal therapy has a realistic chance of being effective. Of course, the more predictors of success there are, the better are the chances that journal therapy can become an active, viable tool in the therapeutic process.

Prior experience with journal writing

Anyone who has written a journal or diary in the past, even those who report negative outcomes, is familiar with the concept and process. Assess by asking the direct question, "Have you ever kept a journal or diary?" If the answer is no, probe further by asking, "Did you keep a diary as a teenager?" or, "Do you ever jot down notes to yourself about your thoughts and feelings, perhaps in your daily planner?"

The little locking diary from late childhood and adolescence is a rite for many adult women growing up in the United States, and women who wrote as preteens or teens are likely to report at least one other episode of turning to journals for emotional support or problem-solving. Male clients are less likely to report direct experiences with journalkeeping, although many men utilize calendar systems such as DayTimers, DayRunners, or Franklin Planners to record events and process notes. This use may be reframed as a type of business diary.

Motivation

Clients who have significant emotional, psychological, or physical pain are highly motivated to try treatment strategies that offer relief or respite from suffering. The journal's accessibility as a container and its availability as a therapeutic presence are often determinants for clients motivated by pain as a locus of control.

Clients frequently declare themselves to be motivated but state that they "just don't have the discipline" for writing. This is a teachable moment. It usually speaks to the client's imbedded assumptions about what keeping a journal involves ("I'm supposed to write every day" or "I'm supposed to keep writing until I get to the bottom of the issue.") Counteract this with the question, "If I could help you find ways to write that don't require much discipline, would you be willing to try?" Then begin with short, structured interventions from the bottom of the journal ladder.

I often tell clients that the only question to which they own allegiance is, "Am I getting the results I want?" When they answer this question affirmatively, motivation shifts to an internal locus of control, and discipline becomes moot. Our task as therapists is to find ways of offering journal therapy that help clients answer affirmatively.

Commitment

Even unmotivated, unwilling clients-for instance, those who are court-ordered into treatment-may be able to commit to the behavioral activity of journalkeeping. These clients must be given clearly defined and well structured tasks, specific instructions about expectations, a consistent method of follow-up, and consistent reinforcement. Anecdotal reports suggest that almost half of involuntary clients report actual benefits from the process and develop an internal motivation to continue.

Positive relationship with writing

Clients who did well in English classes, who have experimented with one or more creative writing forms, who enjoy writing letters, or who say they have "always wanted to write a book" or "always known I was a writer" are excellent candidates for journal therapy.

Positive relationship with therapist

Finally, even if none of the other factors on this list are present, clients with strong therapeutic alliance are usually wiling to take direction and recommendation from their helping professionals. When this is the only predictor of success, it usually is necessary at first for the therapist to take an active role in the journal process, such as giving structured journal "homework" to be completed between sessions, and inviting the client to report on or share the process of writing during the week.

Sometimes when a client's primary or only predictor is a strong therapeutic relationship, the client may think of the therapist as the audience for the journal. You can gently redirect this tendency by encouraging the client to think of his or her "emerging self"-the man or woman he or she will be in 6 months, or at a therapeutic benchmark-as the audience, and you as the witness to the process.

CONTRAINDICATIONS

A few client populations do not respond well to journal therapy treatment. These include:

Thought-disordered clients. Clients who have psychotic episodes or brittle fragmentation may find that writing is disorganizing and reinforces chaotic thought processes. "It's like falling into a black hole in my mind," said one client diagnosed with paranoid schizophrenia, "and I can't crawl back out again. I'm stuck there, swimming around in all these crazy thoughts."

Clients who have difficulty controlling impulse. Therapists often suggest that clients attempt to "write through" abusive urges, but writing in the impulsive moment sometimes has the paradoxical effect of reifying distorted thinking instead of abating it. For example, clients whose rage is directed externally through physical, emotional or sexual abuse, or internally through suicidal or self-mutilating gestures, may find that writing about dangerous impulses serves to anchor in the reasons and justifications for action. Clients with impulse control issues should be encouraged to find appropriate catharsis, and then to use writing to reflect or process when they have achieved a manageable distance.

Clients with severe mood disorders. Journal therapy can be a mixed bag in treating severe mood disorders. Clients with high anxiety or mania often embrace writing as a container for excess energy and a pressure valve to help regulate affective flooding. Nevertheless, when journal productions are consistently pressured, rapidly shifting, labile, tangential, or loose, writing may exacerbate manic states by bringing up a steady stream of overstimulation without appropriate pacing.

Clients with severe depression are also vulnerable to worsening symptoms if they do not undertake journal writing with attention to potential difficulties. In the context of her work in developing creativity, Cameron (1992) offers a methodology known as "morning pages," which involves a daily three-page stream-of-consciousness writing to be done the first thing in the morning, immediately upon awakening. Although this indeed can be an excellent route to reflective, process, and integrative writing, it may be counterproductive for depressed clients. Repetitive extended episodes of unstructured, unboundaried, unpaced writing, attempted the first thing in the morning when the membrane between the conscious and unconscious minds is most permeable, is often devastating to those who suffer from depression. This "first voice" is often the voice of the internalized critic or the hopeless self, and its daily appearance can be tyrannical.

The antidote for both mania and depression is to help clients find ways to build in structure, pacing and containment (see Table 1). The potential beneficial outcomes of morning pages do not have to be sacrificed. Suggest to your client that he or she postpone writing for an hour after awakening, or write fewer pages, or balance the "first voice" with an intentional shift to the voice of the emerging self.

SEVEN TROUBLESHOOTING TIPS FOR THERAPISTS

At this point, I offer seven troubleshooting tips for the therapist.

1. Don't confuse the product with the process. Although almost all writing that comes from an authentic place is effective and even beautiful, therapeutic writing does not place inherent value on "good" writing. A client is better served when the therapist rewards process and therapeutic outcome rather than lyrical, descriptive, or well crafted product. This approach also troubleshoots any tendency on the client's part to take the focus off of authentic expression in favor of the secondary gain of positive reinforcement for creative talent or technical skill.

2. Manage your countertransference. Because journals are inherently private, the risk of voyeurism is present when given access to another's most intimate thoughts and feelings. Monitor your own curiosity factor.

3. Be careful with nondominant-hand writing. This seemingly benign technique can be a wild card. According to Capacchione (1988), the nondominant hand is "hard-wired" to the nondominant hemisphere of the brain, which, for approximately 90% of North Americans, is the right brain. The right brain "specializes" in visual/spatial perception, emotional expression, and intuitive abilities. When used appropriately, therefore, writing with the nondominant hand may offer quick and easy access to feelings, intuition, wisdom, and insight.

When I was working with adult survivors of childhood sexual trauma, I heard many stories of the shadow side of nondominant-hand writing. Writing with the nondominant hand may be effective in accessing whatever is repressed or held at a lessthan-conscious level of the mind. In dozens of cases, clients reported flooding of raw primary process material when they attempted to use nondominanthand writing to access the voice of the "inner child." For many, this technique represented the first time they had active recall of sexual trauma from childhood. Treat nondominant-hand writing with respect, and review the anchors of structure, pacing, and containment with your clients before suggesting this powerful but unpredictable technique.

4. Give permission. In writing, as in therapy, one size does not fit all. Be skeptical of any program of journalkeeping or proponent of journal therapy that insists on a "right" way, method, technique, or style that will work for everyone. None exists. Extend permission and encouragement to experiment with variables such as techniques, times of day, topics, and length of writings until they develop a natural rhythm and journal style.

5. Adapt for cultural differences. All cultural and socioeconomic groups, do not equally value written expression, and it is not available to some. People can tell life stories in many ways. If journal writing is not the best way, encourage expression through art, music, dance, movement, poetry, puppetry, storytelling, or craft. Be creative in finding adaptations for people with disabilities. I have had blind students who wrote on braille computers or with styluses. I have had students with cerebral palsy who left the room to speak journal entries into hand-held tape recorders while others wrote. I have served as scribe for the reminiscences of elders too feeble to hold a pen, and for the spoken poems of preschoolers.

6. Troubleshoot privacy concerns. You'll likely hear stories of privacy violations that range on a continuum from seemingly benign ("My mother snooped in my sock drawer and found my first diary") to atrocious ("My husband read my journal and beat me up"). Regardless of the place on the continuum, those who feel violated usually report the experience as a traumatic assault against the core self, and many clients who are reluctant to write may fear reenactment. Be ready with assurances that therapeutic journals need not be shared with anyone, including you, the therapist. If the client is concerned about potential privacy violations within the household, make suggestions for how to maintain privacy. These might include asking family members to respect privacy (a role-play is often helpful), writing a "keep out!" notice in the front of the journal, storing the journal in a locking filing cabinet or desk drawer, or writing the journal in a password-protected computer program.

7. Read between the lines. What is written is only part of the story. The story behind the story hovers in the white space between and around the words. Learn to listen with open ears. The truth, as we shall next discover, is multilayered.

MAKING UP THE TRUTH

Making things up and fact are two different things, but you may need some of both to get to the truth.-Toni Morrison (in Rainer, 1997, p 109)

Journals are filled with paradox and contradiction, so we shouldn't be surprised that beliefs about journals can be fraught with duality. As only one example, journalers often fervently believe in and demand a right to privacy, while simultaneously censoring their deepest truth and striving to write well for an unseen, uninvited audience.

One of the biggest obstacles to successful therapeutic writing is the two-headed gremlin of "making it real" versus "making it up." "I don't want to write it down, because writing it down makes it real," clients say to me with great conviction, often followed immediately with, "I don't know where that came from; I'm sure I just made it all up."

Therapists also seem to carry the imbedded assumption that anything written in a journal is based in factual reality. Journals support and even promote the relaxation of defenses and the inward reach to greater authenticity. Nearly every system of therapeutic writing includes instructions to write truthfully and to trust what comes, even if the content seems unfamiliar or previously unknown. It is not surprising, then, that both clients and therapists trust journals to let us read minds and hearts and souls at the most literal levels.

This is further underscored by all of the perceived permanence and authority of the written word. Once a thought, an experience, a story, a complex set of feelings is committed to paper through the mystery and magic of the word, it takes on a life of its own, separate and apart from the writer. Once our stories, even those we make up, find form; they are "made real" in an essential and tangible way; they exist. But, as Young (1993) reminds us:

This is the paradox and wonder of journals: What we write stands permanently, but only for the moment. It is not indelible, fixed, or static. A journal entry is but an illuminated fragment of time, a way station between the past and future, a crystallized point on a continuum of change.

As with all paradox, the truth lies within the opposites; the "quest" is in the question. The duality of "writing makes it real" and "I'm making all this up" is resolved when we are able to discern between "factual truth" and "emotional truth." Factual truth in the journal is the literally accurate recording of events and circumstances, the objective reality. This level of truth is, of course, useful and important. Exclusive focus or reliance on factual truth, however, cannot only become an impediment to therapeutic writing but can also become its own way of "making it up." As Metzger (1992) says,

Just as the mind can distract us from what we want to say, so can the desire to chronicle the literal truth. Omission is one of the primary ways to create falsehood, but including every detail is another way to lose the thread. (p. 57)

For every event or circumstance that can be written factually, a myriad of feelings, observations, reactions, reflections, and interpretations can be made only at the level of subjective reality. These contain the emotional truths that can and must be written even though they are not verifiable except as the compass that guides us through internal landscapes, where resonance edges out rationalization and an internal and audible "Yes!" takes precedence over the need to explain. Only when this sense of congruence and authenticity is in place can factual truth and emotional truth merge into meaning, bringing with it an alchemical truth that is its own transformative, healing agent.

Of course, we must guide clients toward a way of telling emotional truth that is both ethical and personally responsible. In her work with "the new autobiography," Rainer (1997) teaches powerful techniques for mixing imagination with memory to arrive at emotional, or poetic, truth that represents reality in a metaphoric way. Experienced creative writers know that using the imagination to remember will bring up some actual buried memories and some inaccurate ones that convey emotion rather than fact. Rainer cautions:

Any technique that is so powerful-like hypnosis, or the free association of traditional psychoanalysis, or writing with the nondominant hand, or making up memories-must be used responsibly. Using this technique to imagine a memory that your father molested you and consider it proof would obviously be irresponsible. The writing could contain a poetic truth . . . but to consider it evidence of actual events would be unwitting and dangerous. (p. 110)

TWO STORIES ABOUT TWO WOMEN

To illustrate the above points I will tell two stories about two women, Elizabeth and Maureen, who had extraordinary experiences with the boundaries of truth, imagination, and reality.

Constructing a Self Through Writing

Writing dark and repressed memories is like the art of glassblowing. Out of grains of pain you can create exquisitely beautiful shapes and objects. But you must approach the work with respect for its danger; only when you are armed with tools and techniques can you work with the flame rather than be consumed by it. (Rainer, 1997, p. 111)

Elizabeth and I met when she was referred to me for journal therapy. She had returned home from college during her second year because she had descended into a depression that rendered her suicidal at worst, and inarticulate and vegetative at best. Her worried parents sent her to a clinical psychologist whose treatment modalities included hypnotherapy.

After 6 months Elizabeth felt brave enough to tell her therapist that for several years, she had heard internal voices. His assessment led to a diagnosis of multiple personality disorder (now known as dissociative identity disorder), and over the next stage of treatment, several "alter" personalities (Putnam, 1989) were revealed under hypnosis that held stories of various emotional and physical traumas from Elizabeth's childhood and early adolescence.

Elizabeth was a "natural" for journal therapy treatment. She enjoyed writing poetry, letters, and stories and had kept a journal since high school that she described as "a friend in need, revealing and comforting." As I scanned her journal productions in our assessment interview, I noticed that she wrote in the voice of several alter personalities, each of which had its own distinctive handwriting, language pattern, and writing style. This was consistent with the journals of dozens of others I had assessed and treated who were diagnosed with multiple personality disorder.

Over the next 3 years, Elizabeth's journals contained complex and multilayered stories with recurring, dramatic trauma themes written in the voices of her alter personalities. In her own adult voice, she also wrote reflective and process entries about her day-to-day issues, struggles, and decisions. In time, her primary care was transferred to me. My treatment plan, which was informed by her journal, included treatment for traumatic stress; solution-focused, presentcentered building of life skills; and psychiatric supervision for antidepressant medication. Gradually, her "alters" dropped away, and she was left with only two voices: her own, and one that was irrational, delusional, paranoid, and self-destructive.

One day Elizabeth told me that the diagnosis of multiple personality disorder had been made erroneously, and that she had "made up" the entire cast of alter personalities, as well as her stories of trauma and abuse. Her journal, she said, had been a vital tool in helping her organize the complex fiction she had created to cover up the psychosis that had been a constant companion since late adolescence.

At first I didn't believe it. How could she have made it all up? I had personally witnessed both her spontaneous and her guided writings over a 3-year period, and I would have sworn that someone could not write so consistently and credibly "in character"-and not just one character, but many. But Elizabeth insisted that she was telling the truth at last.

"When I first started therapy, I knew there was something really wrong with me," she said simply. "I heard voices that told me terrible things. They told me to hurt myself, and that there were spies everywhere. I couldn't trust anyone. I was scared and lonely and sick." In her compromised mental and emotional state, it seemed preferable to carry a misdiagnosis of a dissociative disorder, the etiology of which would have been external, than a more realistic diagnosis of paranoid schizophrenia, which would have required her to accept difficult and painful truths about her core self.

If the story ended here, it might be only a story of factitious disorder, of a pathologically manipulative client, of the dangers of iatrogenic influence in hypnotherapy, or of the need to view client writings with healthy skepticism. But the story doesn't end here.

The rest of the story is this: Elizabeth got better.

We boxed up all the notebooks, binders, and books that held the stories of her trauma and drama. We taped the box shut and placed it in my office closet. She started fresh with a new psychiatric evaluation. Antipsychotic medication was added to her regime. Elizabeth and I worked together another 2 years, during which time she reconstructed relationships with her family, graduated from college with honors, explored her sexuality and the complexity of intimate partnerships, and learned to live holistically with a thought disorder. The last time I heard from her, she was enjoying a well paying career position, she and her partner were hoping to start a family, and she was managing just fine with a minimum of psychotropic medication.

Metzger (1992) tells us that, "To write is, above all else, to construct a self." Through creating a story in the pages of her journal-however fictitious and factitious that story may have been-Elizabeth gave herself important developmental room to grow. She constructed selves that helped her handle the realities of her life. She plunged into the symbolic realm and plumbed the depths of her unconscious. In mythic terms, she made the initiatory descent into the Underworld and emerged with the boon that represented her heart's deepest yearning: the chance for a normal life.

Imagination and Reality

Under the best of circumstances, the process of writing allows one to give oneself over to the imagination, trusting that it will act in one's best interests, trusting that the use of the creative, the descent in language into the self, the rigorous scrutiny of the psyche, the inclination to dare the unknown will seriously enhance one's life. (Metzger 1992, p. 45)

My Thursday morning writing group was embarking on an exploration of personal mythology through autobiographically based fiction. Each group member would create a character who had many of the same strengths, qualities, characteristics, challenges, and desires as the individual member but who was not necessarily hobbled by the restrictions, limitations, and obstacles that the group member experienced in her own life. Through a series of guided writing explorations, we would turn loose the fictional characters with the situations of the members' lives and see what we could learn from them. I emphasized that, because we were working in the realm of fiction, it was perfectly acceptable to "make up" the truth, and the group members agreed to take each others' stories at face value-not to project or assume that the character's story paralleled the storyteller's.

Maureen created a character named Francie who, like herself, was in her mid-40s. Over the first several weeks, Francie revealed herself to be a determined and headstrong yet troubled woman who struggled against being compartmentalized and who yearned for freedom and escape from oppressive people and circumstances. She was evolving into a complex and enigmatic character.

One morning I offered the writing assignment of placing the character at an earlier time in her life and telling a story that would reveal something about how the character was shaped into the woman she was in the present. Maureen's writing catapulted us back in time to Francie's late childhood. The young Francie was a kinesthetic blur of tumbling, diving, racing, pedaling, skating, leaping, and playing. We, the audience, sat enraptured and enchanted until Maureen delivered the O. Henry ending. The present-day Francie was remembering all this from the confines of a wheelchair.

"I swear I don't know where that came from," Maureen said. "It just fell out of my pen. Honest."

The following Wednesday Maureen called. "I won't be in group tomorrow," she said. "I've spent the day in the emergency room. Last night I was doing the same yoga stretches I've done every night for the last 25 years, and I popped my Achilles tendon. You're not going to believe this, but I'm in a wheelchair!"

Did Maureen have a premonition of her stretching accident? Did her bodymind resonate with the metaphor of wheelchair and bring literal truth in alignment with emotional truth? Did Francie reach out from some mythic realm and twist the kaleidoscope so that the roles of creator and creation tumbled into new and interesting patterns? We explored these questions in group the next day, until Pat begged us to end the discussion and begin writing. She had decided, she told us, to have her character win the lottery and retire to Palm Beach!

Maureen returned to group the following week with a deepened understanding of disability, confinement, compartmentalization, and perspective. She told us how she felt discounted and ignored when she couldn't "stand up" to others, and how lonely life was without eye contact. She shared the fear, fatigue, and frustration of navigating a wheelchair on city streets and public places. She certainly understood and felt more compassionate toward her character, Francie, and toward the part of her own psyche that Francie represented.

But there was an even larger story etching its marks on the tablet of Maureen's psyche. She had surrendered her will to a partnership with the creative mysteries within herself, and the outcomes were so unexpected that she could not have "made them up" in literal truth the way they played out when the imaginary world superimposed itself onto her real life. In the much bigger picture, Maureen now has experiential understanding of the imagination, with all its gifts, terrors, and surprises, as a tangible domain.

CONCLUSION

In moments of ecstasy, in moments of despair, the journal remains a silent friend, forever ready to confront, to coach, to cheer, to console. Its potential as a tool for holistic mental health is unsurpassed. (Adams, 1990)

Journal therapy offers a safe channel for the expression of thoughts and feelings, especially those that have seemed unacceptable or unattainable, and the concomitant reflection, process, and integration into the holistic mind-body self. Through the unfolding story of a personal journal, clients can first examine underlying patterns that have governed their lives, and then transform them into purposeful, responsible, and proactive self-direction. Throughout it all, the journal stands steadfast as a permanent record of the journey, the book that no one else can write.

"Keeping a journal has led me to a treasure chest of memories and insight. A glad heart is one of many gifts my journal gives in return for our time together," writes J. Stancill (personal correspondence, July 1998). Her reflections on the image she holds of herself as journalkeeper are further captured in an Alphapoem: Adventurer awaking

beaming.

Changemaker.

Discoverer.

Exploring the inner world of light and darkness and shawdow through words.

Forcefully shinning into

Godspace

Heart and Head, not Head alone, as compass

illuminating

joyfulness

kindness

Light, surrounding, upholding, energizing.

Marvelous

neverending story unfolding to

open doors, open doors, open doors and passionate

quests.

Reality responds tenderly to Heart.

Surrounded by compassion, wars end and wouds heal.

Tenacious

ubiquitous

valiant

writer-in-time

xuberant

Yes. And

zingly-writes on.

FOR FURTHER STUDY

Training in clinical journal therapy is available via home study, onsite training, or residential intensives through the Center for Journal Therapy, 1 888-421-2298 or visit http://www.journaltherapy.com. All programs are approved for continuing education credit by the National Board of Certified Counselors.

Journal therapists are professionally associated through the National Association for Poetry Therapy. Membership is interdisciplinary and open to anyone who appreciates the use of writing, poetry, literature and language arts for growth and healing. For membership or conference information call NAPT, 202-966-2536, or visit http://www.poetrytherapy.org

REFERENCES

Adams, K. ( 1990). Journal to the self New York: Warner Books. Adams, K. (1994). Mightier than the sword. New York: Warner Books. Adams, K. (1996a). Journal writing as a powerful adjunct to therapy, Jour

nal of Poetry Therapy, 10, 31-37.

Adams, K. (I 996b). The structured journal therapy assessment: A report on SO cases. Journal of Poetry Therapy, 10, 77-85. Adams, K. (1998a). Clinical journal therapy. Denver: Center for Journal Therapy.

Adams, K. (1998b). The way of the journal, 2nd ed. Lutherville, MD: Sidran Press.

Baldwin, C. (1977). One to one. New York: M. Evans. Baldwin, C. (1990). Life's companion. New York: Bantam Books. Cameron, J. ( 1992). The artist's way. Los Angeles: JP Tarcher. Capacchione, L. (1979). The creative journal. Athens: Ohio University/ Swallow Press.

Capacchione, L. (1988). The power of your other hand. North Hollywood: Newcastle.

Metzger, D. (1992). Writing for your life. New York: HarperSanFrancisco. Progoff, I. (1959). Depth psychology and modern man. New York: McGraw-Hill.

Progoff, I. (1965). The symbolic and the real. New York: McGraw-Hill. Progoff, I. (1975). At a journal workshop. New York: Dialogue House Library.

Putnam, F. (1989). Diagnosis and treatment of multiple personality disorder. New York: Guilford Press.

Rainer, T. (1978). The new diary. Los Angeles: J. P. Tarcher. Rainer, T. (1997). Your life as story. New York: Tarcher/Putnam. Taylor, J. (1992). Where people fly and water runs uphill. New York:

Warner Books.

Young, W. (1993). Foreword. In K. Adams, The way of the journal. Lutherville, MD: Sidran Press.

Kathleen Adams

Kathleen Adams, MA, LPC, is a psychotherapist in private practice and Founder/Director of the Center for Journal Therapy, Lakewood, Colorado.

Copyright Love Publishing Company Jan 1999
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