Mastery or mystery- Therapeutic writing

Mastery or mystery? Therapeutic writing: a review of the literature JEANNIE WRIGHT Counselling Service, University of Sheffield, Northumberland Road, Sheffield S10 2TT, UK MAN CHEUNG CHUNG Department of Psychology, University of Plymouth, Drakes Circus, Plymouth PL4 8AA, UK ABSTRACT Recent developments in online support and counselling suggest that the users of chat rooms, for example, or the Samaritans’ e-mail `listening’ service, have already discovered the power of writing as a self-help vehicle. Developments in computer-mediated counselling and therapy are essentially text-based and client-driven. The therapeutic use of expressive and reflective writing is not widely recognised in British counselling and therapy circles. The empirical foundations for the therapeutic uses of the literary arts are, however, well established. This review aims to map the use of `writing therapy’ by drawing together cross-disciplinary research and practitioner reports which might support the place of writing as a creative therapy in its own right, whether as an adjunct to face-to-face counselling or as a self-help tool. Introduction Consumer demand for alternatives to the `talking cure’, the traditional, individual, face-to-face, 50-minute hour of counselling and psychotherapy, is indicated both by anecdotal reports of the use of chat rooms and `online therapy’ and by a recent survey initiated at the Maudsley Hospital in London (Graham et al., 2000). When asked about their preferences for the delivery of self-help psychotherapies, 62% of respondents wanted access to self-help therapy via paper-based formats, but 91% of these same respondents wanted access via some form of computer system. The reconstruction of therapeutic practice (McLeod, 1999) in the UK, represented by online counselling or computer-mediated `writing therapy’, has been relatively slow and characterised by practitioner caution (BAC, 1999; Goss et al., 1999; Parker, 1999). Reporting a number of computer treatment systems in clinical service for the treatment of obsessive±compulsive disorder and phobic anxiety disorders, Graham et al. (2000) conclude that `computerised delivery of cognitive± behavioural therapy for psychiatric disorders is developing rapidly’ (p. 331). Downloaded by [University of Malta] at 01:22 11 July 2016 278 Jeannie Wright & Man Cheung Chung The history of using client writing in a therapeutic setting, mostly, but not exclusively, associated with cognitive and behavioural approaches, is long. It could be argued that `writing therapy’ has also been restimulated by the development of narrative approaches (McLeod, 1997) and computer-mediated methods where keyboard and cyberspace have replaced pen and paper. This review will aim to outline the major developments in the therapeutic use of writing in the English language over the last 30 years with an emphasis on recent research in the USA and Europe. Although it will refer to the implications for online therapy, the focus of the review will be the underlying debate along the `mastery’ (scientific) and `mystery’ (humanities) continuum, comparing the theoretical assumptions of both paradigms, their methodologies and their findings about the benefits of therapeutic writing. A continuum exists in the growing body of literature on therapeutic writing between the polarities of a `scientific’ and a `humanities’ approach, or between `mastery and mystery’ (Bakan, 1969, quoted in McLeod, 1994). On an international basis, those practitioners and researchers who come primarily from a literary arts or creative writing background tend to describe the `soothing and healing power of poetry’ (Bolton, 1999a), for example, or `writing to provide a mechanism for psychological insight’ (Hunt, 2000). Drawing on their experience of clinical practice (Fuchel, 1985; Moskowitz, 1998) or of facilitating creative writing groups (Bolton, 1995, 1999a, 2000; Hunt, 2000; Hunt & Sampson, 1998) the therapeutic benefits of writing are explored with an enthusiasm verging on the evangelical. Those who follow a more scientific paradigm, from disciplines including immunology, health and social psychology, seek to `master’ the phenomenon by measuring, explaining, predicting and analysing the results of randomised, controlled trials. Psychologist James Pennebaker and his associates have initiated studies into the empirical foundations for writing about emotional experiences, the results of which have been critiqued, replicated and extended in North America, Europe and many other parts of the world (see Pennebaker & Seagal, 1999). These experiments clearly demonstrate the benefits of `writing therapy’ for both physical and mental health. The increase in and demand for online support and counselling (BAC, 1999) suggest that the users of chat rooms, for example, or the Samaritans’ e-mail support service (Baughan, 2000) have already discovered and are using writing as a self-help tool. More central to potential users’ concerns and to those of practitioners, especially those working within the pressures of a brief/time-limited model, is the question: how can client writing enhance the psychotherapeutic process? These practitioner/researchers give their views: `Perhaps there is no other system of psychotherapy in which the client has so much control over the rate, depth and intensity of his or her personal therapeutic work’ (Rasmussen & Tomm, 1992, p. 3); or `Writing is a kind and comparatively gentle way of facing whatever is there to be faced. You can trust it to pace itself to your needs and wants rather than to anyone else, such as a therapist. It can be private until you decide to share it’ (Bolton, 1999a, p. 12). Downloaded by [University of Malta] at 01:22 11 July 2016 Mastery or mystery? 279 Comparisons between vocal and written expression of feeling about traumatic events have been analysed (Murray & Segal, 1994) and would suggest that there is similar emotional processing by vocal and written expression of feeling. Bolton’s work in `writing therapy’ encompasses far more than writing to disclose feelings about specific, stressful or traumatic experiences however, and `writing therapy’ is not narrowly defined in her publications. Definitions of `writing therapy’ Defining `writing therapy’ is difficultÐ`. . . a useful but vague and poorly defined technique’, in Riordan’s (1996) summaryÐnor is there one neat theoretical model or set of empirical findings to guide the use of therapeutic writing. References to parallels with other expressive and creative therapies, art, movement, drama and music, for example, are clear but there is little systematic explanation as to why writing therapy has not developed to the same extent. For the purposes of this review, writing therapy is defined as client expressive and reflective writing, whether self-generated or suggested by a therapist/researcher. Therefore, the use of writing by the therapist about the client, such as in case notes or in farewell letters (Ryle, 1990), is not included. It is not intended to polarise or oversimplify the body of literature on writing therapy by structuring the review around the scientific/humanities continuum. If anything, as Mazza (1999) argues, both approaches are needed in order to develop the research base and professional practice of writing therapy. The `humanities’ paradigm The National Association for PoetryTherapy (USA) represents the most developed of the therapies which uses creative writing. Standards and ethical guidelines are in place in the USA for Certified Poetry Therapists and Registered Poetry Therapists (Mazza, 1993, p. 51). Mazza (1999) extends an earlier research agenda for poetry therapy and suggests that both quantitative and qualitative research methods are needed at this interface of the arts and psychology. In the UK, Hunt and Sampson (1998), both involved in the organising committee of LAPIDUS (The Association for the Literary Arts in Personal Development), define `writing’ as `what is generally called ª creative writingº, rather than, for example report writing or clinical notes’ (p. 199). They have edited a collection of essays which link autobiographical and expressive writing to personal development and healing. The Self on the Page: Theory and Practice of Creative Writing in Personal Development is useful for its detailed accounts of current practice in a wide range of British educational and healthcare settings. The emphasis in accounts of research undertaken is on qualitative methods. The section on theoretical contexts is a tentative collection of ideas, drawing on psychoanalytic theory, linguistics, symbolic interactionism and philosophy, ancient and modern. The need to synthesise and to work across disciplines in the field of writing therapy is apparent. In her most recent book, Celia Hunt (2000) adopts a Downloaded by [University of Malta] at 01:22 11 July 2016 280 Jeannie Wright & Man Cheung Chung `Horneyan literary±psychoanalytic approach’ to cast-studies of four `highly literate, self-reflective’ women who took part in her `Autobiography and the Imagination’ creative writing course (p. 14). Some of the exercises described, such as `life mapping’, will be familiar to guidance practitioners and counsellors who recall the innovative use of `psychoeducational’ methods in the 1970s (e.g. Figler, 1979; Ivey & Authier, 1971). Hunt explores the complexity of her chosen theoretical model with great tenacity, asking important questions about the tension between writing as art and writing as therapy. She points out the limitations of her approach, however, first in not focusing on broader cultural or sociological questions of class, gender or ethnicity.There is certainly very little sense of the political awareness of constructivist approaches, to be found in some contributions to the field (e.g. Bacigalupe, 1996) where questions of social justice and user preference are addressed. Ethical boundaries are also less than clear, as pointed out by Hunt herself: `There are considerable risks associated with applying psychodynamic theory to the written and spoken words of people one is working with without the safe-guards which would normally be built into the therapeutic relationship’ (Hunt, 2000, p. 191). Gillie Bolton, a poet and leading British practitioner/researcher working largely, but not exclusively, in health care settings, also comes from a background of teaching creative writing. Describing her theoretical model as `eclectic’, the humanistic tradition predominates, and specifically Rogers and Perls are cited. The methods Bolton advocates skilfully marry a number of approaches from creative education and therapeutic practice, for example, the boundaries of confidentiality and `selfempowerment’ of experiential small groups, where the facilitator’s role is not to interpret. Bolton’s (1998a) `Writing or pills: therapeutic writing in primary care’ reports the positive findings of a pilot project carried out under the auspices of the Institute of General Practice at the University of Sheffield. In challenging the British medical profession to undertake a new, creative way of working with patients, she stresses the power of writing in a setting where patients are all too often passive and powerless. One advantage of writing, in Bolton’s view of her research, is that it is: `for patients and by them rather than being done to them. Too much medicine is diagnosis from the outside and having treatments done to the patient’ (Bolton, 1999a, p. 5). Bolton’s work is criticised by some for implying that in self-directed therapeutic writing there are no risks. Conversely, as illustrated by the above and by self-report from a range of participants in writing groups, it is this very emphasis on the potential of therapeutic writing for self-help, prevention and self-directedness which makes it such a viable alternative to those who choose to write, whether or not they enter therapy. Downloaded by [University of Malta] at 01:22 11 July 2016 Mastery or mystery? 281 Some attention is paid here to the question of for whom and under what circumstances writing is most effective. Patients to whom it was appropriate to suggest writing therapy included those suffering from problematic life circumstances rather than chronic depression, for example. Those it would not be useful for included `disturbed or psychotic patients’ who, it was felt, needed more supervision than a GP could offer. A summary of these and other findings will be considered in more detail in the implications for practice section at the end of this paper. Bolton points out that `poetry and medicine have gone hand in hand since Apollo was the god of both’ (Bolton, 1999b, p. 119). Certainly the poetry and `story’ columns in the British Medical Journal and Journal of the American Medical Association are enriching and could be welcome additions to some of the currently somewhat arid counselling and therapy journals published in the UK. Drawing from her extensive experience of running workshops with small groups of women (Bolton, 1999b), and citing examples from modern poetry written by women, including Sylvia Plath and Anne Sexton, the particular persistence of the savage inner critic in women is addressed. Bolton (1995) compares writing as therapy to other expressive therapies: `Like art therapy it offers direct access to a client’s creativity’ (Milner, 1971, p. 216). Although there are similarities between Bolton’s methods and those of the Pennebaker paradigm, such as instructing the client/group in `writing without thinking’ , a clear divergence emerges here. Practitioners and researchers from the cognitive±behavioural/`scientific’ end of the continuum, for whom client creativity and imagination are variables to be reduced if possible, underestimate this most important aspect of `writing therapy’. Bolton’s (1999a) The Therapeutic Potential of Creative Writing: Writing Myself conveys a passion for writing and a range of experience of working with groups who report its physical and psychological benefits. One reviewer called it `a bubbling cauldron of a book’, conveying the sense of wanting to rush out and follow the author’s enthusiasm to try out some of the ideas and exercises. Although Bolton’s ideas and practical examples of ways to begin writing are equally powerful for individual use, it is perhaps the descriptions of group work, many from group participants themselves, which stand out. The harnessing of the expression of hitherto undisclosed emotion and private insights in writing, together with the potential for support and challenge in well-facilitated small groups create results which are difficult to define or explain. Bolton herself, rather than explaining, recommends experiential methods for both potential users of writing therapy and for practitioner/researchers. Could this process be measured, analysed, predicted? Bolton (1999a) refers to Pennebaker and other leading representatives of the scientific paradigm, whose findings on the beneficial effects of writing support her own. In her critique, she points out that Pennebaker and his associates are working from a different model and contests their assumptions about the self. Her own view is: `People are composed of a stewpot of beliefs, understandings, memories, terrors and hopes. Different elements bubble up at different times, wanting Downloaded by [University of Malta] at 01:22 11 July 2016 282 Jeannie Wright & Man Cheung Chung and needing to be attended to. Dealing with these in an appropriate way then and there will lead to a more balanced and happy individual. But there are no right or wrong elements’ (Bolton, 1999a, p. 200). Bolton is not a neutral observer. Her stance draws on a long tradition of the therapeutic use of human creativity in general and writing in particular: `. . . poems are a hotline to our hearts, and we forget this emotional power at our peril’ (Motion, 2000). The possibility of synthesis Family and systemic therapy has been a fruitful area for therapeutic writing and demonstrates the potential for synthesis of science and humanities or `mastery’ and `mystery’. Bacigalupe (1996), practising in an American family therapy and community mental health context, emphasises, like Bolton, the client-centredness of writing with and by the client rather than writing about or to the client. The implications and relevance of client writing for working cross culturally are also highlighted. Bacigalupe also links the participatory basis of writing therapy with the power imbalance within any helping relationship. By writing about particular problem areas, the client becomes expert on their own material, thus challenging the boundaries between what White and Epston (1990) call `expert knowledge’ and `local knowledge’. This is particularly crucial when the social status of the client is inherently subject to discrimination and oppression. `The question of writing in therapy is also relevant to discussions about issues of social justice in therapy contexts (e.g. therapists working with minority families.) Work in a community health clinic can challenge therapists with questions about gender inequalities, institutionalised racism, evolving ethnic and cultural values and classism’ (Bacigalupe, 1996, p. 362). Writing in this context is empowering and inclusive. Examples given from family therapy in Australia and the USA include instances where adolescents and children are encouraged to write about their experience of foster care, for example, and present that writing to the `experts’ on the panel of professionals who hold the power to make decisions over their lives. Describing a systemic innovation which Terperger Rasmussen, a Danish psychiatrist and psychotherapist, initiated in 1979, Rasmussen and Tomm (1992) outline a `long brief therapy’, the core of which is `respect for the client’s selfdirectedness’ (p. 18). Pragmatism, and not wanting to succumb to pressures to abandon his interest in psychotherapy in favour of prescribing medication, was largely Rasmussen’s original motivation for using writing with non-psychotic patients. His approach to guided letter writing emerged in response to the time pressures of the Danish health care Downloaded by [University of Malta] at 01:22 11 July 2016 Mastery or mystery? 283 system and long train journeys incurred by his practice between urban and rural areas. Letters from patients could be read on the train! Within a time-limited model, Rasmussen encourages and supports his clients’ existing resources, including their autonomy and creativity, thus mirroring the `empowerment and self-healing’, which is the focus of Bolton’s work with groups. `In this method, clients are coached to search out and find what they need the most and will do so if the therapist doesn’t interfere too much’ (p. 18). Tomm has applied Rasmussen’s approach in psychiatry in Canada, and outlines his clinical findings. There is no evidence of systematic evaluation. The scientific paradigm If science is the art of the soluble, then Pennebaker and other empiricists have failed. Four leading American researchers (Esterling et al., 1999) admit that `despite the beneficial effects of writing, it is not entirely clear why it is effective in bringing about such striking physical health and behavior change’ (p. 84). The beneficial effects of written emotional expression are, however, clearly and precisely recorded and have been subjected to meta-analysis (Smyth, 1998). One decision on how to categorise this wide-ranging body of work for the purposes of this review could have been chronological and geographic, showing the development of randomised controlled trials, internationally, over a 15-year period and across populations. Instead, to illustrate the wealth of research outcomes within the Pennebaker paradigm, the work of the leaders of the field in the USA and of those in the Amsterdam Writing Project will be highlighted. Reviews of core research on written emotional expression and health (Esterling et al., 1999; Pennebaker, 1993) and `meta-analytic reviews’ of the written emotional expression literature (Smyth, 1998) suggest various benefits, including physiological functioning, e.g. impact on the immune system (see Esterling et al., 1990, 1994; Greenhalgh, 1999; Pennebaker et al., 1988; Smyth et al., 1999). Some potential disadvantages of therapeutic writing are also considered, such as short-term negative mood related to long-term improvements in self-reported psychological well-being (see Pennebaker, 1990, 1993, 1995). Theoretical models to explain the benefits described are less confident. The cognitive±behavioural paradigm predominates, suggesting, for example, that emotionally expressive writing facilitates cognitive processing of traumatic memory, which leads to affective and physiological change (Pennebaker et al., 1990). The links between boosting the immune system and emotional disclosure in writing (Esterling, 1990, 1994) suggest that the therapeutic uses of the literary arts are on a firm psychobiological foundation (Lowe, 2000). Specific chronic illnesses, for example, have been the subject of RCTs using writing about stressful experiences as a `nonpharmacological’ treatment. Smyth et al. (1999), researching the effects of writing with patients with asthma or rheumatoid arthritis, concluded that clinically relevant changes were found in those who had written about stressful life experiences. Headlines such as `The pen is more powerful than the pill’ have drawn popular attention to the efficacy of writing. The economic Downloaded by [University of Malta] at 01:22 11 July 2016 284 Jeannie Wright & Man Cheung Chung implications for such a low-tech, low-cost intervention are discussed in the literature. Similarly, the potential for health care `at a distance’ was recognised before the widespread development of `telehealth’ via the Internet. L’Abate (1991, 1992, 1999a,b), a family therapist working in the USA, has contributed significantly to the literature on the use of writing, specifically with distance and programmed writing materials, which can be used preventively or in computer-assisted training (L’Abate & Baggett, 1997). Known for his humorous suggestion that counsellors should be advised to tell their clients they must write,`unless they 1. like you a lot, 2.have plenty of money, 3. have excellent insurance, and 4. want to stay in therapy for ever!’ (L’Abate, 1992, p. 48), he has also been a major figure in the `mastery/mystery’ debate. He questions traditional modes of family psychotherapeutic practice and advocates new techniques, including writing, that do not rely on therapist±patient talk. His early writing (L’Abate, 1991) shows a controlling, `therapist as expert’ ethos: `Although self-administered by patients, completed assignments are scrutinised by the therapist who then provides corrective feedback. These assignments are used as a springboard for further discussion and exploration in therapy. Generalisations, distortions, deletions and other errors in thinking are pointed out by the therapist and worked through’ (p. 90). Later accounts (Jordan & L’Abate, 1995, 1999) also emphasise the need for`constant correction’ by the therapist as `crucial’. Offering a critique of and advancing Pennebaker’s early work on writing about traumatic experiences, Lange, Schoutrop and colleagues in the Amsterdam Writing Project have used qualitative studies to highlight effective and ineffective ways of writing about trauma. Referring to learning theory as the foundation of the model, Lange (1994, 1996) describes the benefits of `ritualised writing’ and especially letter writing, in reprocessing traumatic events. The methods are directive and involve the therapist giving `precise instructions’ to the patient about `subject matter, the manner of writing, frequency, the amount of time spent and location’ (Lange, 1996, p. 376). Working in family therapy, Lange demonstrates through cast-studies how writing, `a powerful and ª friendlyº technique’ (1994 p. 381), results in self-confrontation leading to cognitive reappraisal. In subsequent studies (Schoutrop et al., 1997a,b; Van Zuuren et al., 1999) the psychologists/researchers inspect the writing in a more open and reflective way. Rather than `searching for a direct relation between writing therapy and an outcome measure’ (Van Zuuren et al., 1999 p. 364) the group aims to study an overview of positive and negative textual features to identify elements in the writing which are indicative of effective or ineffective writing.They also exemplify a less prescriptive style: `the finding that some participants deviated successfully from their assignment could be transformed into the instruction that deviation is Downloaded by [University of Malta] at 01:22 11 July 2016 Mastery or mystery? 285 permitted if the participant considers this useful. Clients might even be offered several types of instructions, in order to be able to choose which type will work best for them’ (p. 377). A greater degree of client self-directedness is implied. Conclusions This review maps how the literature across the continuum has shown that expressive writing can, under some circumstances, improve physical and psychological health. In spite of academic and popular exposure, however, on neither side of the Atlantic is writing `part of the mainstream psychotherapeutic armamentarium’ (Esterling et al., 1999, p. 94). The emergence of online counselling and therapy may change that. Meaningful comparisons in terms of theory, methodologies and findings between the work of researchers and practitioners of such diversity are fraught. The difference between humanistic and cognitive±behavioural psychology, for instance, or between randomised, controlled trials and self-report within cast-studies is the subject of controversy in volumes of theoretical and methodological discourse in the social sciences and psychotherapy and would not be an appropriate focus here. Even where a similar research aim is taken, using similar methodologies, such as investigations into written emotional expression and its effects on post-traumatic stress, variables are impossible to reduce entirely. When similar sample groups of participants are used, for example, a variety of outcome measures have been applied: physiological measures (including immune function), general health measures (e.g. somatic complaints and health centre visits), and psychological measures (cognitive, affective and behavioural effects). Although positive results have been reported for all these domains (e.g. Esterling et al., 1994; Lange, 1994; Pennebaker & Beall, 1986), definitive comparisons are difficult to draw because of variables in follow-up periods, diagnosis of the degree of the initial traumatic experience, or the amount of words actually written. Smyth (1998) takes the medical model to extremes, referring to the amount of writing done as the `dose’. It is this very reductionism which the researcher/practitioners from the humanities end of the continuum tend to eschew. Yet, the concomitant criticism of their research, as merely `anecdotal’, persists. Unsurprisingly, there is little sense of reflexivity in the accounts of the `scientific’ experiments, a quality which is, on the other hand, one of the strengths of the `humanities’ approach, in which the voices of participants also have a central place. What emerges from studying the process and outcomes of such diverse lines of enquiry as Smyth’s (1998) RCTs and Bolton et al.’s (2000) single case-study is the powerful sense of commonality. For some people, in some circumstances, expressive writing is beneficial, with or without the added value of a therapeutic relationship. The narrative approach also emerges as an underlying link. Referring to White and Epston’s (1990) innovative work in family therapy, Hunt (2000) is making similar points about autobiographical narrations, for example, to those of Kuhnlein (1999) Downloaded by [University of Malta] at 01:22 11 July 2016 286 Jeannie Wright & Man Cheung Chung and McLeod (1997) and to Pennebaker and Seagal (1999), though all would start from very different theoretical perspectives. Most often identified with cognitive±behavioural orientations and with cognitive analytic therapy (Ryle, 1983, 1990), there would seem to be a place for `writing therapy’ amongst the expressive therapies across all theoretical orientations. As Bolton (1999a) puts it, `poetry or story making is therapy for both the body and soul’ (p. 27). And one of the reasons writing therapy needs the `scientific’ approach is that the `creative hunches’ of advocates from the `humanities’ body of research are strengthened by corroborative evidence from the other end of the continuum: `Thus scientific methodology is seen for what it truly isÐa way of preventing me from deceiving myself in regard to my creatively informed hunches which have developed out of the relationship between me and my material’ (Rogers, 1955, p. 275). Implications for practice The simplicity of the way in which writing therapy works, if not the precise mechanism, is expressed humbly, after a dense analysis of randomised controlled trials, as follows: `Many people, perhaps most, are able to guide their own therapy. Writing itself is a powerful therapeutic technique’ (Esterling et al., 1999, p. 94). The implications of these findings for online therapy, where writing is the major therapeutic vehicle, are complex. A review of the `literature’, mostly electronic if it is not to be out of date before it is word processed, let alone published, is the subject of another paper which would raise some interesting issues about the move from pencil or pen to keyboard and expressive writing. An analysis comparing typing and writing longhand in terms of disclosure of negative emotions, for example (Brewin & Lennard, 1999), may seem trivial compared to the controversy surrounding the existence and viability of the therapeutic relationship online, but the implications for practice are urgently in need of more systematic application. Similarly, Pennebaker’s work and others, previously cited (see also Cameron & Nicholls, 1998; Bastien & Jacobs, 1974) in which students have been the participants in the majority of randomised controlled trials, needs to be widely applied by practitioners in educational settings. The evidence that writing about stressful or traumatic experiences results in health and other benefits, including improved academic performance (Pennebaker & Francis, 1996), is clear, whether or not we can explain the mechanism that produces that benefit. Writing therapy is cost-effective and would provide students with a self-help vehicle which some have clearly already discovered via the Internet and e-mail lists. There are, however, indications, other than those already mentioned, that writing therapy is not always appropriate or beneficial. When the client’s experience is pre-verbal, for instance, other expressive therapies would be preferred. When writing is associated with strong negative experiences, such as being criticised at Downloaded by [University of Malta] at 01:22 11 July 2016 Mastery or mystery? 287 school, clients are unlikely to want to try writing therapy. One such client, to whom letter writing had been `rotten fish’ (Lange, 1996), said, `I don’t want to read or write about my experiences’. Dyslexia has been another clear contraindication. In addition, the initial negative mood and short-term psychological pain resulting from writing about traumatic events (Esterling et al., 1999) may be intolerable for some unsupported writers (i.e. online). The importance of creating a safe space is thoroughly addressed in the Pennebaker paradigm and also in Bolton’s accounts of working with small groups. Table 1 outlines some of the circumstances in which `writing therapy’ has been beneficial and some examples of supporting evidence. The caution of the therapeutic profession is not matched by that of their potential clients, or by the people using chat rooms and other forms of writing TABLE 1. Circumstances in which `writing therapy’ has been beneficial Supporting evidence Time-limited, focused, brief therapyÐsome of the detail can be dealt with outside the therapy room, on paper and in private; Advantages of `economy and complexity’, e.g. Ryle, 1983, p. 365; Rasmussen & Tomm, 1992 With people who have a self-directed tendency to writeÐjournals, diaries, lettersÐand who have found the process of writing, especially autobiographical writing, cathartic and clarifying; Examples from literature throughout history and as analysed in Hunt, 2000; Hunt & Sampson, 1998 With people who are, or perceive themselves to be, powerless; Bacigalupe, 1996; case material in Wright, 1999, 2000 With people who are not using their first language in the face-to-face therapyÐthey are able to use their first language or a mixture of both first and host language; Wright, 1999 With people who, for cultural or other reasons, are silenced by shame or other inhibiting emotions and feel unable to speak; Bass & Davis, 1988; Bolton, 1999b With people who are in inner turmoil and need to `unpack the mind’, externalise and organise their thoughts and feelings; Bolton et al., 2000; L’Abate, 1992; Riordan, 1996 With people who need to disclose and exorcise a particular memory of stressful or traumatic experience; Pennebaker paradigm reviewed in Smyth, 1998; Esterling et al., 1999; Amsterdam Writing Project summarised in Van Zuuren, 1999 With people at particular stages of life associated with experiencing strong feelings, e.g. adolescence, or with the dying and those in hospice care. Bolton, 1998b Downloaded by [University of Malta] at 01:22 11 July 2016 288 Jeannie Wright & Man Cheung Chung therapy who would not classify themselves as `patients’ or `clients’. It has been suggested, for example, that writing may be more effective for males (Smyth, 1998), who have, traditionally, been underrepresented in statistical analyses of the use of face-to-face counselling services. `Above all, writing may provide an alternative form of preventive therapy that can be valuable for individuals who otherwise would not enter therapy’ (Esterling et al., 1999, p. 92). It is based on this evidence that one of us has introduced `writing therapy’ with a range of clients in time-limited, workplace counselling. A simple sheet of instructions, emphasising the need to silence the `inner critic’ by `writing without thinking’ and without concern for spelling, syntax, neatness and other memories of academic red pens is useful but most important is the potential for clients to come up with their own ideas. One secretary, for example, who had been to assertiveness classes but was still struggling to work with an overbearing manager, started to write what she called `SCREAM SHEETS’. In an evaluation questionnaire, she wrote, `It helped me to vent anger/frustration and allowed me to communicate much more effectively once I actually spoke to that person’. Another, an academic with a tendency to intellectualise about his feelings but who agreed to the suggestion of keeping an emotional diary, wrote that `It helped me raise certain fears/emotions that I was reluctant to admit/confront’. A feeling named is a feeling tamed. Human communication was revolutionised by the invention of writing. Now another revolution has resulted in communication via the Internet. So chat rooms thrive. Learning from both the creative writers and from the scientists of selfdisclosure, another valuable vehicle for self-exploration and change is developing.