The Scottish Intecollegiate Guidelines Network (SIGN) published their guidance on "Non-pharmaceutical management of depression" today.  SIGN comment:  "Depression Alliance Scotland proposed the development of this guideline based on feedback from service users who were seeking information about interventions other than prescribed antidepressants which could be helpful in managing their depression.  The Scottish Integrated Care Pathway (ICP) for depression sets standards for appropriate care and treatment of people with depression. It states that for those who choose a non-pharmacological approach, or for whom medication is not effective, there should be the offer of a brief depression-focused psychological intervention.  There is a need for accessible and robust evidence based information about the alternatives to prescribed antidepressants to be available to both GPs and service users."

They go on to say:  "This guideline provides an assessment of, and presents the evidence base for, the efficacy of non-pharmaceutical therapies, encompassing psychological therapies, structured exercise and lifestyle interventions, and a range of alternative and complementary treatments, many of which are not routinely available within the NHS.  This guideline will be of particular interest to those developing mental health services, health care professionals in primary and secondary care (eg GPs, community psychiatric nurses, clinical psychologists and psychiatrists) and patients with depression and their carers.  It may also be helpful to voluntary organisations and exercise professionals working in exercise referral schemes, public or private fitness centres, and physical activity promotion."

The guidance is freely accessible/downloadable as the full 44 page "Non-pharmaceutical management of depression in adults: a national clinical guideline", as a brief 2 page "Quick reference guide" and as a 32 page "Treating depression without using prescribed medication: booklet for patients and carers".

How good is this guidance?  It's good.  Of course there are areas one can criticise, but overall it's excellent.  A big thank you to the group of clinicians, researchers and members of the general public, who volunteered and worked for years to put this guideline together.  The obvious comparison is the recent English/Welsh "Updated NICE guidelines on treating depression".  SIGN's effort is welcome because it steers clear of the much written about subject of antidepressant medication and concentrates on the crucially important area of non-pharmaceutical management.

What are the key points?  Well SIGN's "A grade" recommendations (grading reflects the strength of the underlying research evidence) are for various forms of psychotherapy - behavioural activation (BA), cognitive behavioural psychotherapy (CBT), and interpersonal psychotherapy (IPT).  For self-help, SIGN give an A grade to guided self-help based on BA or CBT (including via computer programmes).  Their still strong "B grade" recommendations (good underlying research backing, but not as extensive as for A grades) are for problem solving therapy and short term psychodynamic psychotherapy.  There's a B grade recommendation too for group mindfulness-based cognitive therapy (MBCT) to reduce risk of relapse for people who have already suffered three or more episodes of depression.  Interestingly and encouragingly, there's a further B grade recommendation for forms of structured exercise.

SIGN also make a series of "best practice" points about appropriate training of psychotherapists, appropriate styles of self-help group, the potential value of couples-focused therapy, and the importance of healthy lifestyle.  Sadly, SIGN have fallen into line with the typical establishment position on St John's wort, suggesting that health professionals should not recommend its use because of concerns about standardisation of dose and interactions with other medications.  In the original draft guideline, SIGN gave St John's wort an A grade recommendation.  I wrote extensively about this in "Draft SIGN non-pharmacological depression treatments guideline, 3rd post: herbs & supplements".  The points I made are still valid.  In fact, in a burst of enthusiasm, I wrote nine blog posts about the original SIGN draft guideline.  Several of these commentaries still seem worth reading - for example the already mentioned post on St John's wort, and another on the "Therapeutic alliance in the treatment of depression".  Overall though, a big thumbs up for this guideline, for all who contributed to it, and for Ruth Lang, retired Information and Support Officer for the charity Depression Alliance Scotland, who inspired and initiated the whole process.

They taught me more about, in the midst of all this trauma and suffering and uncertainty - of remaining true to who you are,
and what love can be about in those moments. And there are three or four of those that really stand out very strongly,
whose lives were very different but who were kind of my teachers.
A therapist describing the impact on himself of working with clients struggling with AIDS

You can access a downloadable Word format version of this post by clicking here.

I have already written a couple of blog posts on therapeutic writing - an initial "Writing (& speaking) for resilience & wellbeing 1: introduction" and the more recent "Writing (& speaking) for resilience & wellbeing 2: traumas & difficulties".  Jamie Pennebaker and colleagues first started publishing research on expressive writing back in 1986.  Subsequent work has rightly highlighted the value of writing (or speaking) deeply, honestly and emotionally about one's personal stresses.  Crises are typically profoundly upsetting.  Quite often though participants report that, when they write about the same issue on a series of occasions, the topic becomes a bit less painful.  Some successful research has used writing instructions that deliberately tries to help subjects "process" the traumas that they have faced (Gidron, Duncan et al. 2002 - abstracts & links to all papers mentioned are given further down this post), and other researchers have even encouraged subjects to explore learning and growth that might have occurred following their crisis (Stanton, Danoff-Burg et al. 2002; McCullough, Root et al. 2006; Watkins, Cruz et al. 2008).

This territory should be approached cautiously and sensitively by therapists.  What a nightmare it might be to go for help because of a horrible trauma that has happened in my life, only to find my therapist trying to push some pre-conceived idea on me that - not only has this awful thing occurred - but also I'm now supposed to somehow find "benefits' from the trauma!  A good friend, who has had more than his share of dreadful life events, calls them AFGO's - "another f***ing growth opportunity". 

Richard Tedeschi and Lawrence Calhoun at the University of North Carolina have been particularly active in researching this area of possible posttraumatic growth (Tedeschi and Calhoun 2004; Calhoun and Tedeschi 2004).  They highlight:  "Most of us, when we face very difficult losses or great suffering, will have a variety of highly distressing psychological reactions. Just because individuals experience growth does not mean that they will not suffer. Distress is typical when we face traumatic events.  We most definitely are not implying that traumatic events are good - they are not. But for many of us, life crises are inevitable and we are not given the choice between suffering and growth on the one hand, and no suffering and no change, on the other.  Posttraumatic growth is not universal. It is not uncommon, but neither does everybody who faces a traumatic event experience growth.  Our hope is that you never face a major loss or crisis, but most of us eventually do, and perhaps you may also experience an encounter with posttraumatic growth."

They also explain:  "what is posttraumatic growth?  It is positive change experienced as a result of the struggle with a major life crisis or a traumatic event. Although we coined the term posttraumatic growth, the idea that human beings can be changed by their encounters with life challenges, sometimes in radically positive ways, is not new. The theme is present in ancient spiritual and religious traditions, literature, and philosophy. What is reasonably new is the systematic study of this phenomenon by psychologists, social workers, counselors, and scholars in other traditions of clinical practice and scientific investigation.  what forms does posttraumatic growth take?  Posttraumatic growth tends to occur in five general areas. Sometimes people who must face major life crises develop a sense that new opportunities have emerged from the struggle, opening up possibilities that were not present before. A second area is a change in relationships with others. Some people experience closer relationships with some specific people, and they can also experience an increased sense of connection to others who suffer. A third area of possible change is an increased sense of one's own strength - "if I lived through that, I can face anything". A fourth aspect of posttraumatic growth experienced by some people is a greater appreciation for life in general. The fifth area involves the spiritual or religious domain. Some individuals experience a deepening of their spiritual lives, however, this deepening can also involve a significant change in one's belief system."

This is thought-provoking and potentially wise territory.  New possibilities, deepening of relationships, an increased sense of strength, appreciation of life, existential and spiritual change.  Tedeschi and Calhoun developed the "Posttraumatic growth inventory" as a questionnaire to explore these possibilities.  They write that they are happy for the scale to be employed for research purposes as long as financial gain does not occur from its use.  See their website at UNC Charlotte for more information and freely downloadable research papers.  Clearly it is important to employ this measure sensitively and only when it seems it might be indicated e.g. if the client themself seems open to looking at possible posttraumatic growth.  This might occur after they have already written and/or talked more directly about what happened and shared the emotions and thoughts associated with the trauma.  When I use this scale, it is sometimes as much for its "educational function" in alerting the person to these issues.  And, as the quote from one of their research papers at the head of this blog post highlights, personal growth can be experienced by therapists too who work with trauma survivors (Arnold, Calhoun et al. 2005). 

Arnold, D., L. G. Calhoun, et al. (2005). "Vicarious posttraumatic growth in psychotherapy." Journal of Humanistic Psychology 45(2): 239-263.  [Free Full Text] 
Previous investigations of the impact of trauma-related psychotherapy on clinicians have emphasized the hazardous nature of such work. The present study is the first exploration of clinicians' perceptions of trauma work to investigate in depth the positive consequences of working with trauma survivors. A sample of 21 psychotherapists participated in a naturalistic interview exploring the impact of trauma work with a particular focus on (a) changes in memory systems and schemas about self and the world (the hallmarks of vicarious traumatization) and (b) perceived psychological growth.  In addition to reporting several negative consequences, all of the clinicians in this sample described positive outcomes. These descriptions of positive sequelae are strikingly similar to reports of growth following directly experienced trauma and suggest that the potential benefits of working with trauma survivors may be significantly more powerful and far-reaching than the existing literature's scant focus on positive sequelae would indicate.

Calhoun, L. G. and R. G. Tedeschi (2004). "The Foundations of Posttraumatic Growth: New Considerations." Psychological Inquiry 15(1): 93-102.  [Free Full Text] 
In response to comments on our model of posttraumatic growth, we consider the validity of reports of posttraumatic growth, appropriate methodology to use to assess posttraumatic growth, and its relation with other variables that appear to bear a resemblance to posttraumatic growth (e.g., well-being and psychological adjustment).  The potentially important role of proximate and distal cultural factors is also addressed.  Clinicians are encouraged to use interventions that facilitate posttraumatic growth with care, so as not to create expectations for posttraumatic growth in all trauma survivors, and to instead promote a respect for the difficulty of trauma recovery while allowing for the exploration of possibilities for various kinds of growth even in those who have suffered greatly.

Gidron, Y., E. Duncan, et al. (2002). "Effects of guided written disclosure of stressful experiences on clinic visits and symptoms in frequent clinic attenders." Fam Pract 19(2): 161-6.  [Free Full Text]
 BACKGROUND: Psychosocial variables such as major stressful life events/daily stressful events have been associated with health care utilization. OBJECTIVE: Our aim was to examine the effects of a guided disclosure protocol (GDP) of past traumas on symptoms and clinic visits among frequent clinic attenders. METHODS: Forty-one frequent clinic attenders (>/=2 visits/3 months) took part. Patients were randomly assigned individually to either a casual content writing control group (n = 19) or a trauma content writing experimental GDP group (n = 22). GDP patients wrote about an upsetting event chronologically (day 1), verbally described their thoughts and feelings and described the event's impact on life (day 2), and finally wrote about their current perspective on and future coping with the event (day 3). Three months later, patients were reassessed blindly for symptoms and clinic visits, and an average of 15 months later they were assessed blindly for clinic visits again. RESULTS: Compared with controls, GDP patients reported lower symptom levels at 3 months (2.3 versus 5.2), and made fewer clinic visits during the 3 (1.3 versus 3.0) and 15 month (5.1 versus 9.7) follow-ups. The percentage of GDP patients making >/=10 visits during the 15 month follow-up was smaller (10%) than among controls (33%). CONCLUSIONS: The findings extend previous findings to frequent clinic users, using a new form of written disclosure aimed at shifting trauma from implicit to explicit memory. The GDP may be an inexpensive additional intervention in primary care for reducing symptoms and clinic visits among frequent clinic users.

McCullough, M. E., L. M. Root, et al. (2006). "Writing About the Benefits of an Interpersonal Transgression Facilitates Forgiveness." Journal of Consulting and Clinical Psychology 74(5): 887-897.  [PubMed]
The authors examined the effects of writing about the benefits of an interpersonal transgression on forgiveness. Participants (N = 304) were randomly assigned to one of three 20-min writing tasks in which they wrote about either (a) traumatic features of the most recent interpersonal transgression they had suffered, (b) personal benefits resulting from the transgression, or (c) a control topic that was unrelated to the transgression. Participants in the benefit-finding condition became more forgiving toward their transgressors than did those in the other 2 conditions, who did not differ from each other. In part, the benefit-finding condition appeared to facilitate forgiveness by encouraging participants to engage in cognitive processing as they wrote their essays. Results suggest that benefit finding may be a unique and useful addition to efforts to help people forgive interpersonal transgressions through structured interventions. The Transgression-Related Interpersonal Motivations Inventory-18-Item Version (TRIM-18) is appended.

Stanton, A. L., S. Danoff-Burg, et al. (2002). "Randomized, controlled trial of written emotional expression and benefit finding in breast cancer patients." J Clin Oncol 20(20): 4160-8.  [PubMed]
PURPOSE: Expressing emotions and finding benefits regarding stressful experiences have been associated in correlational research with positive adjustment. A randomized trial was performed to compare effects of experimentally induced written emotional disclosure and benefit finding with a control condition on physical and psychological adjustment to breast cancer and to test whether outcomes varied as a function of participants' cancer-related avoidance. PATIENTS AND METHODS: Early-stage breast cancer patients completing medical treatment were assigned randomly to write over four sessions about (1) their deepest thoughts and feelings regarding breast cancer (EMO group; n = 21), (2) positive thoughts and feelings regarding their experience with breast cancer (POS group; n = 21), or (3) facts of their breast cancer experience (CTL group; n = 18). Psychological (eg, distress) and physical (perceived somatic symptoms and medical appointments for cancer-related morbidities) outcomes were assessed at 1- and 3-month follow-ups. RESULTS: A significant condition x cancer-related avoidance interaction emerged on psychological outcomes; EMO writing was relatively effective for women low in avoidance, and induced POS writing was more useful for women high in avoidance. Significant effects of experimental condition emerged on self-reported somatic symptoms (P =.0183) and medical appointments for cancer-related morbidities (P =.0069). Compared with CTL participants at 3 months, the EMO group reported significantly decreased physical symptoms, and EMO and POS participants had significantly fewer medical appointments for cancer-related morbidities. CONCLUSION: Experimentally induced emotional expression and benefit finding regarding early-stage breast cancer reduced medical visits for cancer-related morbidities. Effects on psychological outcomes varied as a function of cancer-related avoidance.

Tedeschi, R. G. and L. G. Calhoun (2004). "Posttraumatic Growth: Conceptual Foundations and Empirical Evidence." Psychological Inquiry 15(1): 1-18.  [Free Full Text] 
This article describes the concept of posttraumatic growth. its conceptual foundations, and supporting empirical evidence. Posttraumatic growth is the experience of positive change that occurs as a result of the struggle with highly challenging life crises.  It is manifested in a variety of ways, including an increased appreciation for life in general, more meaningful interpersonal relationships, an increased sense of personal strength, changed priorities, and a richer existential and spiritual life.  Although the term is new, the idea that great good can come from great suffering is ancient. We propose a model for understanding the process of posttraumatic growth in which individual characteristics, support and disclosure, and more centrally, significant cognitive processing involving cognitive structures threatened or nullified by the traumatic events, play an important role. It is also suggested that posttraumatic growth mutually interacts with life wisdom and the development of the life narrative, and that it is an ongoing process, not a static outcome.

Watkins, P. C., L. Cruz, et al. (2008). "Taking care of business? Grateful processing of unpleasant memories." The Journal of Positive Psychology 3(2): 87-99.  [Abstract/Full Text] 
In this study we investigated the impact of grateful processing on bringing closure to unpleasant emotional memories. After recalling an open memory, participants were randomly assigned to one of three writing conditions. For three sessions, participants wrote about neutral topics, the unpleasant event itself, or positive consequences from the event from their open memory that they felt they could now be grateful for. Results showed a significant effect of writing condition, and the pattern of means were as predicted: those in the grateful condition showed more memory closure, less unpleasant emotional impact, and less intrusiveness of the open memory than the other writing conditions. Grateful reappraisal of unpleasant memories may help individuals emotionally process these events, thus bringing emotional closure to these incidents. This might be one reason that grateful people tend to be happy people.

I'm a member of three different groups, all of which meet occasionally in the evening.  Since two of the groups only get together about every six weeks, it's unusual for all three group meetings to occur in the same seven days.  In fact I can't remember it happening before.  It's happening this week though - hence the trigger for this blog post "Different kinds of group, different kinds of friendship". 

The group that meets pretty much every week is probably the most straightforward.  We've been getting together for many years to play badminton for a couple of hours.  It's great.  I hugely enjoy it.  It's warm too - we're friendly and we joke a lot.  We encourage each other and we're very competitive as well.  However with most of these guys, I hardly meet them except to play badminton.  I could tell you very little about how their lives are going, or about how they're usually feeling.

In a previous blog post "Relationships, self-esteem and health" I've mentioned Sheldon Cohen's fine work.  Cohen has convincingly proposed that social intimacy, social integration, and social conflict all make independent contributions to our health and wellbeing - we want higher scores for intimacy and integration and (usually) lower scores for conflict.  I've put together a simple three item questionnaire - the "Personal community activities scale" to get some idea of how people are doing in these areas.  It's not hard science, but it's a pretty good rough & ready assessment tool (for fuller assessment methods see the "Relationships in general" page).  The second question looks at "social integration" stating "For wellbeing, most people ... appreciate sharing activities, interests & having fun with others (for example, eating together, working on a project, going out to theatres, films & concerts, walking, sport, learning, creativity, voluntary work, having a drink, coffee or tea, etc) - have you had enough of this shared activity time in your life?"  The question asks for an estimate on a 0 (none) to 100 (perfect for me) scale how the last week (or other agreed time period) has been for these "social integration" shared activities.  Playing badminton hits this spots very well. 

The badminton doesn't really contribute much though to the area highlighted by the first question on the scale, which asks about "social intimacy" - "For wellbeing, most people benefit particularly from emotionally close relationships where they can talk meaningfully and feel understood & valued - have you had enough of this emotional closeness in your life (with people who you can relate to in this way, who are available and who you make enough of the right kind of time & place for)?"  Again the answer is scored on the 0 (none) to 100 (perfect for me) scale.

The second group I'm involved with straddles both social intimacy (emotional closeness) and social integration (shared activity).  It's a book group.  We got together a couple of days ago on Sunday evening.  Good talking.  Good sharing about the reading we had been doing.  Lots of affection, humour, smiles, interest.  We've been meeting for years.  It's lovely and also gets us reading a whole load of literature we wouldn't otherwise have explored.  The conversation does become more personal at times, but that's not the aim of the group.  Deeper personal sharing only happens "tangentially" as people reflect on what the author has been writing about and the thoughts and feelings this has triggered in us.  Fun.  Delightful.  A great group.

Last night I also got together with another (overlapping) group of friends.  We call this the "Enquiry Group".  It evolved some years ago from an urge I had to meet up socially with other "expert therapists".  We spent a fair amount of times over the initial sessions exploring why we might want to meet and how we might spend the time.  Eventually we settled on this "enquiry" focus that we have used pretty consistently ever since.  As with the badminton and book groups, the membership evolves over time as some people drop out and others join.  Most of us are therapists, but not all.  At the moment there are 9 in the group - soon probably to be 10.  This size of group may be a little too big for purpose (for limited evening time slots), but usually we can't all get to every meeting.  The "enquiry process" could be designed for "social intimacy".  After checking in as a whole group over a cup of tea, we split into subgroups of 3 to 5 people.  Typically we will have come up with a question or area we would like to explore.  Subjects we've chosen over the meetings include "Death and dying", "How I feel being here with you guys", and most regularly "How I'm feeling right now is ... ".  Last night we worked with "The new year, the new decade ... ".  We each got only about quarter of an hour - 10 minutes or so to speak about "The new year, the new decade", and 5 minutes or so for the other 3 people in the subgroup to comment, give feedback, and ask questions.  I think in the original enquiry method, the suggestion is that the speaker is uninterrupted and the rest of the group just listen silently.  After the 10 or so minutes talking (the timing depends on how long we have and how many are in the subgroup), the listeners have maybe 5 minutes to respond.  The suggestion is that the responses focus mainly on simply asking questions that might help the speaker reflect more deeply on what they have been saying.  Actually we know each other pretty well and we're - well I certainly - am an inveterate "rule breaker" in these kinds of exercises, so often the feedback deviates from this "simply ask questions that could deepen the speaker's reflection" instruction.

It's full of riches.  I give clients psychotherapy sessions that run for between 60 to 75 minutes.  In the 10 minutes we each had to talk last night, most of us seemed to go as deep emotionally as one might in a really precious psychotherapy session.  It's like dropping down a well or over a cliff.  I've tried in the past, talking from a more intellectual, "heady" space.  It's dissatisfying, at least for me.  So in this enquiry process, I very deliberately soak down into my body and my feelings, sharing what emerges - a process of "not knowing" and "finding out".  These are at levels five to seven on the well-known "Experiencing scale".  This kind of "intimacy" and closeness soaks into my body.  It profoundly changes me.  I said last night something like "For me, it feels as if we somehow perform some kind of magic ritual, a mystery".  An apparent paradox is that this deep, personal, witnessed, inner exploration also links us deeply with each other.  It takes courage.  It's also helped by our experiences and familiarity with working at emotional levels.  Great.  Joyful.

Last week I wrote about the helpful GPPAQ exercise screening questionnaire in "Exercise 2: UK Department of Health, resources for assessment & advice".  This week I'd like to go "over the pond" to visit the excellent advice on exercise provided by the US government.  One of the most useful resources is the Department of Health & Human Services (HHS) website publicising the 2008 "Physical activity guidelines for Americans".  There is a downloadable two page "At-a-glance: a fact sheet for professionals", as well as the 8.5Mb full 76 page guideline itself.  The full guideline is actually a pretty good read.  It isn't particularly technical and is aimed at general audiences.  Many people may however prefer just to read specific chapters that are of particular personal interest - click on online chapter by chapter to access this option.  

There also two very practical, very helpful downloads - the 28 page "Be active your way: booklet" for adults, and the 2 page "Be active your way: a fact sheet for adults".  If I had access to only two handouts on exercise, these currently are my favourites.  The more general US HHS Healthfinder.gov website also provides a very useful Get active section based on the 2008 activity guidelines.

I like these American guidelines for a series of reasons:

• The full guideline provides specific advice for several different groups of people - children & adolescents, adults, pregnant & postpartum women, older adults, people with disability, and people with chronic medical conditions. 
• They move beyond the helpfully simple, but too black & white, take 30 minutes of exercise per day prescription (or twice this amount for kids).  The advice is on how much exercise to take per week, and this is more flexible and more realistic.
• The guidelines make a useful distinction between moderate exercise (I can talk while I do it, but I can't sing) and vigorous exercise (I can only say a few words without stopping to catch my breath).  For adults, they suggest an initial target of 150 minutes of moderate or 75 minutes of vigorous exercise per week (or a mix of the two), but they also highlight that going beyond this initial target makes good health sense.   
• The importance of strengthening exercises is also recognized.  People are encouraged - on at least two days per week - to strengthen the major muscle groups involving legs, hips, back, chest, stomach and shoulders.  Exercises for each muscle group should be repeated for 8 to 12 repetitions per session.

Good stuff.  More academic, and also useful, are the American College of Sports Medicine (ACSM) "position stand" reviews on a variety of topics including "Appropriate Physical Activity Intervention Strategies for Weight Loss and Prevention of Weight Regain for Adults", "Progression Models in Resistance Training for Healthy Adults" and "Exercise and Physical Activity for Older Adults".

In the last in this series of 4 posts on exercise, next week I'll mention a variety of websites that provide other good exercise resources.

Fear is the mind-killer ... I will face my fear. I will permit it to pass over me and through me. And when it has gone past I will turn the inner eye to see its path. Where the fear has gone there will be nothing. Only I will remain.  Bene Gesserit "Litany against Fear" from "Dune" by Frank Herbert

You can access a downloadable Word format version of this post by clicking here  .

Last week I wrote "Writing (& speaking) for resilience & wellbeing 1: an introduction" which began this series of posts on different types of therapeutic writing.  It is 25 years since the first expressive writing study (Pennebaker & Beall 1986 - see below for abstracts & links to all research studies mentioned in this post) found that individuals who wrote about a personally traumatic life event for 15 minutes daily over four days had fewer health centre visits during the next six months than control participants who wrote about superficial topics.  Interest in this simple, potentially powerful intervention flourished - there have now been over two hundred research studies exploring the effects of different kinds of therapeutic writing.  Jamie Pennebaker's website lists many of these publications.  Fascinatingly it has been found that writing expressively about important aspects of our lives can strengthen our resilience to stress and boost our wellbeing.  These effects involve improvements in mood, problem-solving, relationships, immune function, wound healing, stress hormones, and vulnerability to illness. 

Over the years, I have lectured and taught many people this "focus on traumas and difficulties" form of therapeutic writing.  The website page "Life review, traumatic memories & therapeutic writing" provides links to a series of downloads that are relevant here.  See, for example, the dozen slides in "Power of words 1" and "Power of words 2", and the printable sets of how-to-do-it instructions "Therapeutic writing by Jamie Pennebaker" and "Therapeutic writing by James Hawkins".

Virtually all of us have "skeletons in our cupboards" - life experiences that we have found upsetting and possibly even traumatising.  As Mol, Arntz et al (2005) found "Life events can generate at least as many PTSD (posttraumatic stress disorder) symptoms as traumatic events".  Holding on to this material excessively can damage us - see for example research listed in "Self-concealment: background information".  The "Self-concealment scale" is an helpful window into this territory.  Try scoring yourself on this questionnaire.  It's been found that "A high tendency to conceal was associated with increased physical and psychological illness, even after allowing for the presence or absence of past trauma".  And past trauma is very common.  Probably most people suffering from anxiety and depression have earlier life traumas and difficulties that contribute to their current distressing symptoms.  See for example the eighteen slides listed in a presentation I gave a while ago - "Importance of traumatic memories 1", "Importance of traumatic memories 2" and "Importance of traumatic memories 3".  This sequence can be printed out as three (6 miniatures to a page) handouts. 

We all are likely to experience emotional reactions to events in our lives.  Ideally these emotions energise and guide us to respond adaptively.  Sadly this isn't always the case.  Our emotions sometimes seem excessive or inappropriate to the situation that triggers them.  This "inappropriateness" may indicate that emotional processing work might be helpful.  See for example the two-slide handout "Emotions, arriving & leaving" or the form "Understanding our reactions: self-monitoring" .  The therapeutic writing handouts already mentioned give suggestions on how to use writing to process such material.  There are also good books on the subject.  See, for example, Jamie Pennebaker's practical "Writing to Heal" or other helpful books listed on his website.

There's so much that I could write about all this.  However, now, I just want to make half a dozen more, brief points.  One is to highlight that, although this type of expressive writing usually focuses on past experiences, it can also be very helpful to write about current difficulties (Barclay & Skarlicki 2009; Graham, Lobel et al. 2008) or even about feared future events that haven't yet happened (Dalton & Glenwick 2009).  A second point is that a tendency to ruminate (Sloan, Marx et al. 2008) or worry (Goldman, Dugas et al. 2007) may well indicate that there is benefit to be had from this type of expressive writing.  Thirdly I'd emphasise that it's likely to be important to dig really deeply into our emotions & thoughts and, at least initially, to try to see the situation from how one actually experienced it at the time (Kuyken & Moulds 2009).  Fourthly - again with this particular form of trauma/difficulty-focused expressive writing - it may be sensible to write on a number of occasions about the same subject rather than chop and change too much (Sloan, Marx et al. 2005).  Fifthly I would take the usual "write continuously for 15 to 20 minutes on 3 to 4 consecutive days" instruction with a pinch of salt.  In fact writing for longer or shorter, less or more continuously, and at varied intervals between the writing sessions have all shown good effects (Smyth & Pennebaker 2008).  The standard instruction just happens to be the one that was used most frequently in research trials.  It's a good basic format to use, but optimal "dose", "frequency", and "number of sessions" in any given situation are all issues that aren't yet properly resolved.  Possibly a better way forward in exploring dose/frequency questions is by monitoring response using measures of continuing emotional upset and helpful/unhelpful beliefs and judgements.  And this is the sixth and final point.  Expressive writing focusing on trauma and difficulties is a great self-help method and stress management tool.  However with difficult traumas and problematic posttraumatic stress reactions it makes sense to see a therapist who is experienced in this kind of work.  Therapeutic writing as normally prescribed typically isn't "enough" in such situations (Smyth, Hockemeyer et al. 2008; Bugg, Turpin et al. 2009).  But as a self-help tool or component of therapy, expressive writing is well worth knowing about and trying out.  

Next week, I'll write about "Writing (& speaking) for resilience & wellbeing 3: personal growth" .

Barclay, L. J. and D. P. Skarlicki (2009). "Healing the wounds of organizational injustice: examining the benefits of expressive writing." J Appl Psychol 94(2): 511-23.  [PubMed]
Clinical and health psychology research has shown that expressive writing interventions-expressing one's experience through writing-can have physical and psychological benefits for individuals dealing with traumatic experiences. In the present study, the authors examined whether these benefits generalize to experiences of workplace injustice. Participants (N = 100) were randomly assigned to write on 4 consecutive days about (a) their emotions, (b) their thoughts, (c) both their emotions and their thoughts surrounding an injustice, or (d) a trivial topic (control). Post-intervention, participants in the emotions and thoughts condition reported higher psychological well-being, fewer intentions to retaliate, and higher levels of personal resolution than did participants in the other conditions. Participants in the emotions and thoughts condition also reported less anger than did participants who wrote only about their emotions.

Bugg, A., G. Turpin, et al. (2009). "A randomised controlled trial of the effectiveness of writing as a self-help intervention for traumatic injury patients at risk of developing post-traumatic stress disorder." Behaviour Research and Therapy 47(1): 6-12.  [Abstract/Full Text]
The study investigated the effects of writing and self-help information on severity of psychological symptoms in traumatic injury patients at risk for developing post-traumatic stress disorder (PTSD). Patients attending Accident and Emergency (A & E), were screened for Acute Stress Disorder and randomised to an information control group (n = 36) or a writing and information group (n = 31). Participants in both groups received an information booklet one-month post-injury. Participants in the writing group also wrote about emotional aspects of their trauma during three 20-min sessions, five to six weeks post-injury. Psychological assessments were completed within one month and at three and six months post-injury. There were significant improvements on measures of anxiety, depression and PTSD over time. Differences between groups on these measures were not statistically significant. However, subjective ratings of the usefulness of writing were high. In conclusion, the results do not currently support the use of writing as a targeted early intervention technique for traumatic injury patients at risk of developing PTSD.

Dalton, J. J. and D. S. Glenwick (2009). "Effects of expressive writing on standardized graduate entrance exam performance and physical health functioning." J Psychol 143(3): 279-92.  [PubMed] 
A substantial body of literature has demonstrated that expressive writing about an individual's deepest thoughts and feelings regarding a past or ongoing stressful experience results in a wide range of beneficial effects, including physical health and cognitive functioning. The authors examined the effects of writing about a future stressful experience - an impending graduate entrance exam - by comparing the exam performance and physical health functioning of participants who wrote about their deepest thoughts regarding the exam with those of participants who wrote about neutral and nonemotional topics. The experimental group reported a mean exam score that was significantly (19 percentile points) higher than that of the comparison group (i.e., the control group). The participants in the experimental group who wrote on 3 - compared with fewer - occasions experienced the greatest benefits. The authors propose possible causal mechanisms for the results and suggest future research questions and applications.

Goldman, N., M. J. Dugas, et al. (2007). "The impact of written exposure on worry: a preliminary investigation." Behav Modif 31(4): 512-38.  [PubMed]
The main goal of this study was to examine the effect of written exposure on generalized anxiety disorder (GAD)-related symptoms in high worriers. Thirty nonclinical high worriers were randomly assigned to either a written exposure condition or a control writing condition. Self-report measures were used to assess worry, GAD somatic symptoms, depression, and intolerance of uncertainty at four time points during the study. Using hierarchical linear modeling (HLM), the authors found that all symptoms (i.e., worry, GAD somatic symptoms, and depression) significantly decreased over time in the written exposure group (although GAD somatic symptoms also decreased in the control group). Moreover, consistent with previous findings that intolerance of uncertainty preceded changes in worry over the course of treatment, intolerance of uncertainty scores predicted subsequent scores on all symptom measures in the experimental group. In contrast, worry and depression scores predicted subsequent intolerance of uncertainty scores in the control group.

Graham, J. E., M. Lobel, et al. (2008). "Effects of written anger expression in chronic pain patients: making meaning from pain." J Behav Med 31(3): 201-12.  [PubMed]
Based on prior research demonstrating benefits of emotional disclosure for chronically ill individuals and evidence that anger is particularly problematic in chronic pain sufferers, outpatients from a chronic pain center (N=102) were randomly assigned to express their anger constructively or to write about their goals non-emotionally in a letter-writing format on two occasions. Letters were coded for degree of expressed anger and meaning-making (speculation and insight into conditions that precipitated anger). Over a 9 week period, participants in the anger-expression group (n=51) experienced greater improvement in control over pain and depressed mood, and marginally greater improvement in pain severity than the control group (n=51). Degree of expressed anger uniquely accounted for intervention effects and meaning-making mediated effects on depressed mood. These findings suggest that expressing anger may be helpful for chronic pain sufferers, particularly if it leads to meaning-making.

Kuyken, W. and M. L. Moulds (2009). "Remembering as an observer: how is autobiographical memory retrieval vantage perspective linked to depression?" Memory 17(6): 624-34.  [PubMed]
It has long been noted that the emotional impact of an autobiographical memory is associated with the vantage perspective from which it is recalled (Freud, 1950). Memories recalled from a first-person "field" perspective are phenomenologically rich, while third-person "observer" perspective memories contain more descriptive but less affective detail (Nigro & Neisser, 1983). Although there is some evidence that depressed individuals retrieve more observer memories than non-depressed individuals (e.g., Kuyken & Howell, 2006), little is known of the cognitive mechanisms associated with observer memories in depression. At pre- and post-treatment, 123 patients with a history of recurrent depression completed self-report measures and the autobiographical memory task (AMT). Participants also indicated the vantage perspective of the memories recalled on the AMT. Observer memories were less vivid, older, and more frequently rehearsed. The tendency to retrieve observer perspective memories was associated with greater negative self-evaluation, lower dispositional mindfulness, and greater use of avoidance. Furthermore, participants who recalled more field perspective memories at pre-treatment had lower levels of post-treatment depression, controlling for pre-treatment levels of depression and trait rumination. We apply contemporary accounts from social and cognitive psychology, and propose potential mechanisms that link the tendency to retrieve observer perspective memories to depression.

Mol, S. S., A. Arntz, et al. (2005). "Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study." Br J Psychiatry 186: 494-9.  [PubMed] 
BACKGROUND: Post-traumatic stress disorder (PTSD) is the only psychiatric condition that requires a specific event to have occurred for its diagnosis. AIMS: To gather evidence from the adult general population on whether life events (e.g. divorce, unemployment) generate as many symptoms of post-traumatic stress as traumatic events (e.g. accidents, abuse). METHOD: Data on demographic characteristics and history of stressful events were collected through a written questionnaire sent to a random sample of 2997 adults. Respondents also filled out a PTSD symptom checklist, keeping in mind their worst event. Mean PTSD scores were compared, controlling for differences between the two groups. Differences in item scores and in the distribution of the total PTSD scores were analysed. RESULTS: Of the 1498 respondents, 832 were eligible for inclusion in our analysis. For events from the past 30 years the PTSD scores were higher after life events than after traumatic events; for earlier events the scores were the same for both types of events. These findings could not be explained by differences in demographics, history of stressful events, individual item scores, or the distribution of the total PTSD scores. CONCLUSIONS: Life events can generate at least as many PTSD symptoms as traumatic events. Our findings call for further studies on the specificity of traumatic events as a cause of PTSD.

Pennebaker, J. W. and S. K. Beall (1986). "Confronting a traumatic event: toward an understanding of inhibition and disease." Journal of Abnormal Psychology 95(3): 274-81.  [PubMed]
According to previous work, failure to confide in others about traumatic events is associated with increased incidence of stress-related disease.  The present study served as a preliminary investigation to learn if writing about traumatic events would influence long-term measures of health as well as short-term indicators of physiological arousal and reports of negative moods.  In addition, we examined the aspects of writing about traumatic events (i.e., cognitive, affective or both) that are most related to physiological and self-report variables.  Forty-six healthy undergraduates wrote about either personally traumatic life events or trivial topics on 4 consecutive days.  In addition to health center records, physiological measures and self-reported moods and physical symptoms were collected throughout the experiment.  Overall, writing about both the emotions and facts surrounding a traumatic event was associated with relatively higher blood pressure and negative moods following the essays, but fewer health center visits in the 6 months following the experiment.  Although the findings and underlying theory should be considered preliminary, they bear directly on issues surrounding catharsis, self-disclosure, and a general theory of psychosomatics based on behavioural inhibition.

Sloan, D. M., B. P. Marx, et al. (2005). "Further examination of the exposure model underlying the efficacy of written emotional disclosure." J Consult Clin Psychol 73(3): 549-54.  [PubMed] 
In the current study, the authors examined the effects of systematically varying the writing instructions for the written emotional disclosure procedure. College undergraduates with a trauma history and at least moderate posttraumatic stress symptoms were asked to write about (a) the same traumatic experience, (b) different traumatic experiences, or (c) nontraumatic everyday events across 3 written disclosure sessions. Results show that participants who wrote about the same traumatic experience reported significant reductions in psychological and physical symptoms at follow-up assessments compared with other participants. These findings suggest that written emotional disclosure may be most effective when individuals are instructed to write about the same traumatic or stressful event at each writing session, a finding consistent with exposure-based treatments.

Sloan, D. M., B. P. Marx, et al. (2008). "Expressive writing buffers against maladaptive rumination." Emotion 8(2): 302-6.  [PubMed]
This study examined whether ruminative style moderated the effects of expressive writing. Sixty-nine participants were assessed for ruminative style and depression symptoms at the beginning of their 1st college semester. Participants were then randomized to either an expressive writing or a control writing condition. Changes in depression symptoms were assessed 2, 4, and 6 months later. Results showed that a brooding ruminative style moderated the effects of expressive writing such that among those assigned to the expressive writing condition, individuals with greater brooding scores reported significantly fewer depression symptoms at all of the follow-up assessments relative to individuals with lower brooding scores. In contrast, reflective pondering ruminative style did not moderate the effects of expressive writing on depression symptoms. These findings suggest that expressive writing could be used as a means of reducing depression symptoms among those with a maladaptive ruminative tendency to brood.

Smyth, J. M. and J. W. Pennebaker (2008). "Exploring the boundary conditions of expressive writing: In search of the right recipe." Br J Health Psychol 13(Pt 1): 1-7.  [PubMed] 
This is a great introduction to the journals special section on "Boundary conditions of expressive writing" and its 19 associated articles.  What once appeared to be a straightforward intervention is turning out to be much more complex than initially thought.

Smyth, J. M., J. R. Hockemeyer, et al. (2008). "Expressive writing and post-traumatic stress disorder: Effects on trauma symptoms, mood states, and cortisol reactivity." British Journal of Health Psychology 13: 85-93.  [Abstract/Full Article] 
Objectives: This study investigates the boundary conditions (feasibility, safety, and efficacy) of an expressive writing intervention for individuals with post-traumatic stress disorder [PTSD].  Design: Randomized trial with baseline and 3-month follow-up measures of PTSD severity and symptoms, mood states, post-traumatic growth, and (post-only) cortisol reactivity to trauma-related stress.  Methods: Volunteers with a verified diagnosis of PTSD (N=25) were randomly assigned to an experimental group (writing about their traumatic experience) or control group (writing about time management).  Results: Expressive writing was acceptable to patients with PTSD and appeared safe to utilize. No changes in PTSD diagnosis or symptoms were observed, but significant improvements in mood and post-traumatic growth were observed in the expressive writing group. Finally, expressive writing greatly attenuated neuroendocrine (cortisol) responses to trauma-related memories.  Conclusions: The present study provides insight into several boundary conditions of expressive writing. Writing did not decrease PTSD-related symptom severity. Although patients continue to exhibit the core features of PTSD, their capacity to regulate those responses appears improved following expressive writing. Dysphoric mood decreased after writing and when exposed to traumatic memories, participants' physiological response is reduced and their recovery enhanced.

I recently asked a computer-literate friend how I could encourage more people to visit this blog (thank you to all who already do!).  He said "Write more about sex and violence."  Ouch.  I replied, rather self-righteously, that I wasn't just interested in increasing website traffic for its own sake - that the primary purpose of this blog is to be helpful.  Well here I go - some good research studies on sex (and couples) that I hope are helpful!

So in "Who's afraid of the G-spot?", (abstracts and links for all studies mentioned are listed further down this post) Jannini and colleagues discuss arguments for and against this possible "gynaecological UFO".  It seems present understanding is that the G-spot region " ...  is not a constant, but can be highly variable from woman to woman", and also that there seem to be "dynamic changes in the G-spot during digital and penile stimulation".  There's useful information for all would-be wonderful lovers.  Shamloul then looks at "Natural aphrodisiacs".  He suggests that "The search for a remedy or a prescription that can enhance sexual function and/or treat male erectile dysfunction (ED) has been an obsession throughout known history."  One of his only cautiously supportive comments is that "Although there's a positive trend towards recommending ginseng as an effective aphrodisiac, however, more in depth studies involving large number of subjects and its mechanism of action are needed before definite conclusions could be reached."  He concludes "The current body of objective evidence does not support the use of any natural aphrodisiac as an effective treatment for male or female sexual dysfunctions. Potent men and men with ED will continue the search for natural aphrodisiacs despite the current disappointing data on their effectiveness. Care should be taken regarding the fraud addition of sildenafil (Viagra) analogues to natural aphrodisiacs."  The continued high spending on probably ineffective "natural aphrodisiacs" may partly be explained by de Araujo and colleagues' paper "The Management of Erectile Dysfunction with Placebo Only: Does it Work?"  They conclude (unsurprisingly for students of mind-body effects) that " ... treatment of ED with oral placebo capsules demonstrates clinical effects, improving erectile function and quality of erection."

Possibly more interesting than any of these papers is the one by Gager and Yabiku "Who Has the Time? The Relationship Between Household Labor Time and Sexual Frequency" giving further research support to the adage that males who help with housework are more sexually attractive to their partners than couch potatoes who disappear into newspaper sports pages, TV watching, or other less supportive activities.

And three further studies on couples.  Saxbe and Repetti report on "For better or worse? Coregulation of couples' cortisol levels and mood states", unsurprisingly finding that "Partner's negative mood was positively associated with own negative mood for both husbands and wives. Marital satisfaction fully moderated this effect, reducing the strength of the association between one's own and one's partner's negative mood states."  So although how we feel is definitely linked to how our partners are feeling, we tend to be dragged down less by our partners' negative moods if our overall relationship is in better shape - " ... spouses' fluctuations in negative mood and cortisol levels are linked over several days and ... marital satisfaction may buffer spouses from their partners' negative mood or stress state."

Horberg and Chen report (in "research speak") that "Three studies tested the activation and consequences of contingencies of self-worth associated with specific significant others, that is, relationship-specific contingencies of self-worth. The results showed that activating the mental representation of a significant other with whom one strongly desires closeness led participants to stake their self-esteem in domains in which the significant other wanted them to excel."  In other words if your desired partner wants you to look like a sex god/goddess or achieve huge financial success, then it's hard for you not to become strongly influenced by this.  Similarly though, if your partner deeply admires you for qualities like kindness or courage, then this will help you value these qualities more in yourself.  Other researchers have reported parallel findings - for example Rusbult et al's recent paper "The part of me that you bring out: Ideal similarity and the Michelangelo phenomenon".  Be careful who you choose as a partner.  As the old Spanish proverb goes "God said: Take what you want.  Take whatever you want, and pay for it!"  And it seems likely these value effects are also relevant for parent-child relationships, between friends, and even in therapist-client relationships.

This point about choosing your partner well (and treating your partner well) is underlined further by the last paper I mention in this post - Feeney and Thrush's "Relationship influences on exploration in adulthood: the characteristics and function of a secure base."  They report that "Results indicated that the 3 identified characteristics of a secure (attachment) base (availability, noninterference, and encouragement) are strongly predictive of exploration behavior."  In other words, partners who are psychologically available to us, and who encourage us in non-interfering ways, help us to grow as people and have the courage to live our dreams.

Jannini, E., A. , B. Whipple, et al. (2010). "Who's Afraid of the G-spot?" Journal of Sexual Medicine 7(1pt1): 25-34.  [Abstract/Full Text] 
Introduction. No controversy can be more controversial than that regarding the existence of the G-spot, an anatomical and physiological entity for women and many scientists, yet a gynecological UFO for others.  Methods. The pros and cons data have been carefully reviewed by six scientists with different opinions on the G-spot. This controversy roughly follows the Journal of Sexual Medicine Debate held during the International Society for the Study of Women's Sexual Health Congress in Florence in the February of 2009.  Main Outcome Measure. To give to The Journal of Sexual Medicine's reader enough data to form her/his own opinion on an important topic of female sexuality.  Results. Expert #1, who is JSM's Controversy section editor, reviewed histological data from the literature demonstrating the existence of discrete anatomical structures within the vaginal wall composing the G-spot. He also found that this region is not a constant, but can be highly variable from woman to woman. These data are supported by the findings discussed by Expert #2, dealing with the history of the G-spot and by the fascinating experimental evidences presented by Experts #4 and #5, showing the dynamic changes in the G-spot during digital and penile stimulation. Experts #3 and #6 argue critically against the G-spot discussing the contrasting findings so far produced on the topic.  Conclusion. Although a huge amount of data (not always of good quality) have been accumulated in the last 60 years, we still need more research on one of the most challenging aspects of female sexuality.

Shamloul, R. (2010). "Natural Aphrodisiacs." Journal of Sexual Medicine 7(1pt1): 39-49.  [Abstract/Full Text] 
Introduction. The search for a remedy or a prescription that can enhance sexual function and/or treat male erectile dysfunction has been an obsession throughout known history. Whether it was an Eastern civilization or a Western one, religious or atheist, man's aspiration for a better or best "manhood" has been a history-time goal.  Aim. This review will discuss the current research done on the most popular natural aphrodisiacs and examine the weight of evidence to support or discourage the use of any of these substances to enhance sexual desire and/or function.  Methods. Review of the current evidence on the use of natural substances as aphrodisiacs.  Main Outcome Measures. Efficacy of natural aphrodisiacs in enhancing sexual function in men and women.  Results. There is little evidence from literature to recommend the usage of natural aphrodisiacs for the enhancement of sexual desire and/or performance. Data on yohimbine's efficacy does not support the wide use of the drug, which has only mild effects in the treatment of psychogenic ED. Although there's a positive trend towards recommending ginseng as an effective aphrodisiac, however, more in depth studies involving large number of subjects and its mechanism of action are needed before definite conclusions could be reached. Data on the use of natural aphrodisiacs in women is limited.  Conclusions. The current body of objective evidence does not support the use of any natural aphrodisiac as an effective treatment for male or female sexual dysfunctions. Potent men and men with ED will continue the search for natural aphrodisiacs despite the current disappointing data on their effectiveness. Care should be taken regarding the fraud addition of sildenafil analogues to natural aphrodisiacs.

de Araujo, A. C., F. G. da Silva, et al. (2009). "The Management of Erectile Dysfunction with Placebo Only: Does it Work?" Journal of Sexual Medicine 6(12): 3440-3448.  [Abstract/Full Text] 
Introduction. Randomized clinical trials (RCT) remain the gold standard in providing scientific evidence in medical practice in spite of the significant placebo effect in the treatment of several disorders. Although the first-line therapy for erectile dysfunction (ED) is oral phosphodiesterase type-5 inhibitor (iPDE5), the placebo effect in RCT of iPDE5 for ED occurs at a rate as high as 50%.  Aims.  To evaluate the role of therapeutic illusion in the oral treatment for ED.  Methods.  A prospective, controlled, single-blind, parallel-group study was performed at single-center. One hundred and twenty-three patients with ED were randomly assigned into three groups and received different letters: Group 1 (G1) was informed to be receiving a substance for ED treatment; Group 2 (G2) was informed that they could be receiving an active drug or placebo; Group 3 (G3) was conscious to be using placebo. Starch capsules were dispensed to all patients. Median follow up was 12 weeks.  Main Outcome Measures.  ED improvement was assessed after 8 weeks of the intervention by the erectile function domain of the International Index of Erectile Function (IIEF) and the Quality of Erection Questionnaire. ED severity was classified by the IIEF erectile function (IIEF-EF) domain score into five categories: no ED (score of 26-30), mild (22-25), mild to moderate (17-21), moderate (11-16), and severe (6-10). Improvement in IIEF-EF domain was considered as a change in category of severity.Results.  ED severity improved in all three groups (G1 = 31.7%, P = 0.039; G2 = 36.8%, P = 0.028; G3 = 36.8%, P = 0.002) and no difference was found among groups (P = 0.857). Improvement of quality of erection score was only significant in G2 (P = 0.005) and G3 (P < 0.001).  Conclusions.  Written-suggested therapeutic illusion for patients with ED has no major influence in the outcomes. However, treatment of ED with oral placebo capsules demonstrates clinical effects, improving erectile function and quality of erection.

Gager, C. T. and S. T. Yabiku (2009). "Who Has the Time? The Relationship Between Household Labor Time and Sexual Frequency." Journal of Family Issues 31 (2): 135-163.  [Abstract/Full Text]    
Motivated by the trend of women spending more time in paid labor and the general speedup of everyday life, the authors explore whether the resulting time crunch affects sexual frequency among married couples. Although prior research has examined the associations between relationship quality and household labor time, few have examined a dimension of relationship quality that requires time: sexual frequency. This study tests three hypotheses based on time availability, gender ideology, and a new multiple-spheres perspective using the National Survey of Families and Households. The results contradict the hypothesis that time spent on household labor reduces the opportunity for sex. The authors find support for the multiple-spheres hypothesis suggesting that both women and men who "work hard" also "play hard." Results show that wives and husbands who spend more hours in housework and paid work report more frequent sex.

Saxbe, D. and R. L. Repetti (2010). "For better or worse? Coregulation of couples' cortisol levels and mood states." J Pers Soc Psychol 98(1): 92-103.  [PubMed] 
Although a majority of adults live with a close relationship partner, little is known about whether and how partners' momentary affect and physiology covary, or "coregulate." This study used a dyadic multilevel modeling approach to explore the coregulation of spouses' mood states and cortisol levels in 30 married couples who sampled saliva and reported on mood states 4 times per day for 3 days. For both husbands and wives, own cortisol level was positively associated with partner's cortisol level, even after sampling time was controlled. For wives, marital satisfaction weakened the strength of this effect. Partner's negative mood was positively associated with own negative mood for both husbands and wives. Marital satisfaction fully moderated this effect, reducing the strength of the association between one's own and one's partner's negative mood states. Spouses' positive moods were not correlated. As expected, within-couple coregulation coefficients were stronger when mood and cortisol were sampled in the early morning and evening, when spouses were together at home, than during the workday. The results suggest that spouses' fluctuations in negative mood and cortisol levels are linked over several days and that marital satisfaction may buffer spouses from their partners' negative mood or stress state.

Horberg, E. J. and S. Chen (2010). "Significant others and contingencies of self-worth: activation and consequences of relationship-specific contingencies of self-worth." J Pers Soc Psychol 98(1): 77-91.  [PubMed] 
Three studies tested the activation and consequences of contingencies of self-worth associated with specific significant others, that is, relationship-specific contingencies of self-worth. The results showed that activating the mental representation of a significant other with whom one strongly desires closeness led participants to stake their self-esteem in domains in which the significant other wanted them to excel. This was shown in terms of self-reported contingencies of self-worth (Study 1), in terms of self-worth after receiving feedback on a successful or unsatisfactory performance in a relationship-specific contingency domain (Study 2), and in terms of feelings of reduced self-worth after thinking about a failure in a relationship-specific contingency domain (Study 3). Across studies, a variety of contingency domains were examined. Furthermore, Study 3 showed that failing in an activated relationship-specific contingency domain had negative implications for current feelings of closeness and acceptance in the significant-other relationship. Overall, the findings suggest that people's contingencies of self-worth depend on the social situation and that performance in relationship-specific contingency domains can influence people's perceptions of their relationships.

Feeney, B. C. and R. L. Thrush (2010). "Relationship influences on exploration in adulthood: the characteristics and function of a secure base." J Pers Soc Psychol 98(1): 57-76.  [PubMed]
This investigation advances theory and research regarding relationship influences on exploration in adulthood. This is accomplished by (a) identifying important characteristics of a secure base, (b) examining the influence of the presence or absence of these characteristics on exploration behavior in adulthood, and (c) identifying individual-difference factors that are predictive of the provision and receipt of secure base support. In 2 sessions, married couples (N = 167) provided reports of relationship dynamics involving exploration, and they participated in an exploration activity that was videotaped and coded by independent observers. Results indicated that the 3 identified characteristics of a secure base (availability, noninterference, and encouragement) are strongly predictive of exploration behavior, and that the provision and receipt of these behaviors can be predicted by individual differences in attachment. Implications of results and contributions to existing literature are discussed.

Last week I wrote a blog post "Exercise 1: checking it's safe to start".  In today's post I talk about resources provided by the Department of Health (for England & Wales).  They have an excellent webpage on Physical Activity with links to a series of important initiatives including its publication "At least five times a week" which reviews research on exercise & health.  However what I'd like to concentrate on in this post is the recent and helpful General Practice Physical Activity Screening Questionnaire (GPPAQ).  There is a 22 page "GPPAQ booklet" available (updated in May 2009) which contains background advice about using the GPPAQ.  I've also produced a one-page, motivational handout "Health benefits of physical exercise" from information in the booklet.  

The GPPAQ takes less than a minute to complete, is well researched, and has clear recommendations on its use.  You can download copies of this questionnaire by clicking on "GPPAQ NHS PDF version" or "GPPAQ Word version" .  The availability of a quick, simple, exercise screening tool is a real step forward.  As health professionals we have faffed around for too long asking dubiously vague questions like "Do you exercise pretty regularly?"  The GPPAQ assesses both the physical activity involved during one's working day and also during one's leisure time.  The latter is classified into five categories - physical exercise like jogging, swimming, football, etc; cycling; walking; housework/childcare; and gardening/DIY.  From scores on work and leisure time activity, one is assessed as Inactive, Moderately Inactive, Moderately Active, or Active.  This Physical Activity Index (PAI) then forms the basis for subsequent exercise advice.  

Answers to the latter three categories of leisure time activity (walking, housework/childcare, & gardening/DIY) are not initially included in people's final score for the PAI.  This is because, during validation of the questionnaire, it became clear that people found it hard to estimate accurately the quantity and intensity of exercise in these categories.  When someone reports that they walk regularly, but their Physical Activity Index (PAI) is less than Active, it's usually helpful to explore a bit more thoroughly the quantity and intensity of their walking.  See the download "Assessing health benefits from walking" for a straightforward way of doing this.  I've also included a download "GPPAQ physical activity index (PAI)" which provides a grid for quick assessment of someone's PAI. 

The GPPAQ background booklet goes on to state "Patients who receive a score of less than active should be offered a Brief Intervention in Physical Activity in line with the NICE Guidance (2006)"  It points out:

• When providing physical activity advice, primary care practitioners should take into account the individual's needs, preferences and circumstances.
• They should agree goals with them. They should also provide written information about the benefits of activity and the local opportunities to be active.
• Where appropriate offer a referral into a condition specific or exercise on referral programme, if they are available locally.
• They should follow them up at appropriate intervals over a 3 to 6 month period.
• For those with CHD risk of greater than 30% over ten years, the GPPAQ should be completed annually

... useful stuff ... not only for British General Practitioners, but for health professionals generally and for all of us who are interested in better physical and psychological health.  Next week I write on the broader information available from the US in "Exercise 3: US Department of Health & Human Services, resources for assessment & advice".

The universe is full of magical things patiently waiting for our wits to grow sharper.   Eden Phillpotts

You can access a downloadable Word format version of this post by clicking here  .

Introduction:  This is the first in a series of blog posts that aim to provide a brief, "state of the art" review of where 25 years of research on therapeutic writing has got us to so far.  These posts primarily focus on providing advice on evidence-based ways that individuals can use writing to reduce stress, improve physical health, and increase wellbeing.  The bulk of relevant research has flowered from Jamie Pennebaker's pioneering work on the benefits of expressive writing for emotional processing of difficulties and traumas (Smyth and Pennebaker 2008 - all research studies mentioned have abstracts listed further down this post).  However a series of other research groups have, more recently, developed writing applications that emerge from different understandings of what might also strengthen resilience and nourish wellbeing.  Examples I introduce - in addition to writing about traumas - include personal growth, dissonance theory, affirmation theory, attachment applications, and positive psychology.  Usually these forms of therapeutic writing are done "privately" but, for some applications, sharing the writing - for example on the internet - can give additional benefits (Chretien, Goldman et al. 2008).

Speaking & writing:  It is also worth pointing out that, in the relatively few research studies comparing writing with talking, it's been shown that these two forms of "outer" expression can be similarly helpful (Esterling, Antoni et al. 1994;; Murray and Segal 1994) - in contrast to the typical unhelpfulness of "inner" rumination and worry.  If you're feeling creative this suggests fascinating ways in which conversations can be made highly beneficial - in therapy (Kelley, Lumley et al. 1997; Greenberg & Malcolm 2002), in couple relationships (Ditzen, Hoppmann et al. 2008; Suls, Green et al. 1997), in families, and between friends (Finkenauer and Rimé 1998).  This writing to speaking "translation" has become easier now we know more about the benefits achieved through focus on diverse topics (see later posts) like "best possible selves", "intense peak experiences", valued areas of our lives, and so on.  No doubt these effects of deeper conversations partly explain why close relationships are so important for health and wellbeing (Dickens, McGowan et al. 2004; Reis, Sheldon et al. 2000).  If you're feeling really creative, it's even possible to adapt some of these ideas into internal exercises as forms of imagery, prayer and meditation.

For more on therapeutic writing, see next week's "Writing (& speaking) for resilience & wellbeing 2: traumas & difficulties" and subsequent posts.

Chretien, K., E. Goldman, et al. (2008). "The reflective writing class blog: using technology to promote reflection and professional development." J Gen Intern Med 23(12): 2066-70.  [PubMed] 
INTRODUCTION: The hidden (informal) curriculum is blamed for its negative effects on students' humanism and professional development. To combat this, educational initiatives employing mentored reflective practice, faculty role-modeling, and feedback have been advocated. AIM: Promote reflection on professional development using collaborative, web-based technology. SETTING: Four-week basic medicine clerkship rotation at an academic institution over a one-year period. PROGRAM DESCRIPTION: Students were asked to contribute two reflective postings to a class web log (blog) during their rotation. They were able to read each other's postings and leave feedback in a comment section. An instructor provided feedback on entries, aimed to stimulate further reflection. Students could choose anonymous names if desired. PROGRAM EVALUATION: Ninety-one students wrote 177 posts. One-third of students left feedback comments. The majority of students enjoyed the activity and found the instructor's feedback helpful. Assessment of the posts revealed reflections on experience, heavily concerned with behavior and affect. A minority were not reflective. In some cases, the instructor's feedback stimulated additional reflection. Certain posts provided insight to the hidden curriculum. DISCUSSION: We have discovered that blogs can promote reflection, uncover elements of the hidden curriculum, and provide opportunities to promote professional development.

Dickens, C. M., L. McGowan, et al. (2004). "Lack of a close confidant, but not depression, predicts further cardiac events after myocardial infarction." Heart 90(5): 518-22.  [PubMed] 
OBJECTIVE: To assess the role of depression and lack of social support before myocardial infarction (MI) in determining outcome in a large representative sample of patients admitted after MI in the UK. DESIGN: Prospective cohort design. PATIENTS: 1034 consecutive patients were screened 3-4 days after MI. MAIN OUTCOME MEASURES: Mortality and further cardiac events over one year after an MI. RESULTS: At 12 months' follow up mortality and further cardiac events were assessed in 583 of 654 eligible patients (90% response); 140 of 589 for whom baseline data were collected (23.8%) were depressed before their MI. Patients who were depressed before their MI were not more likely to die (mortality 5.2% v 5.0% of non-depressed patients) or suffer further cardiac events (cardiac events rate 20.7% v 20.3% of non-depressed patients). After controlling for demographic factors and severity of MI, the absence of a close confidant predicted further cardiac events (hazard ratio 0.57, p = 0.022). CONCLUSION: Lack of a close confidant but not depression before MI was associated with adverse outcome after MI in this sample. This association may be mediated by unhealthy behaviours and lack of compliance with medical recommendations, but it is also compatible with difficulties in early life leading to heart disease.

Ditzen, B., C. Hoppmann, et al. (2008). "Positive Couple Interactions and Daily Cortisol: On the Stress-Protecting Role of Intimacy." Psychosom Med 70(8): 883-889.  [Abstract/Full Text]  
Objective: To determine whether intimacy might be associated with reduced daily salivary cortisol levels in couples, thereby adding to the epidemiologic literature on reduced health burden in happy couples. Methods: A total of 51 dual-earner couples reported time spent on intimacy, stated their current affect quality, and provided saliva samples for cortisol estimation approximately every 3 hours in a 1-week time-sampling assessment. In addition, participants provided data on chronic problems of work organization. Results: Multilevel analyses revealed that intimacy was significantly associated with reduced daily salivary cortisol levels. There was an interaction effect of intimacy with chronic problems of work organization in terms of their relationship with cortisol levels, suggesting a buffering effect of intimacy on work-related elevated cortisol levels. Above this, the association between intimacy and cortisol was mediated by positive affect. Intimacy and affect together explained 7% of daily salivary cortisol variance. Conclusions: Our results are in line with previous studies on the effect of intimacy on cortisol stress responses in the laboratory as well as with epidemiologic data on health beneficial effects of happy marital relationships.

Esterling, B. A., M. H. Antoni, et al. (1994). "Emotional disclosure through writing or speaking modulates latent Epstein-Barr virus antibody titers." Journal of Consulting and Clinical Psychology 62(1): 130-40.   [PubMed] 
Healthy Epstein-Barr virus (EBV) seropositive undergraduates (N = 57) completed a personality inventory, provided blood samples, and were randomly assigned to write or talk about stressful events, or to write about trivial events, during three weekly 20-min sessions, after which they provided a final blood sample. Individuals assigned to the verbal/stressful condition had significantly lower EBV antibody titers (suggesting better cellular immune control over the latent virus) after the intervention than those in the written/stressful group, who had significantly lower values than those in the written/trivial control group. Subjects assigned to the written/stressful condition expressed more negative emotional words than the verbal/stressful and control groups and more positive emotional words than the verbal/stressful group at each time point. The verbal/stressful group expressed more negative emotional words compared with the control group at baseline. Content analysis indicated that the verbal/stressful group achieved the greatest improvements in cognitive change, self-esteem, and adaptive coping strategies.

Finkenauer, C. and B. Rimé (1998). "Keeping Emotional Memories Secret : Health and Subjective Well-being when Emotions are not Shared." Journal of Health Psychology 3(1): 47-58.  [Abstract/Full Text]
The present study investigated two predictions derived from inhibition theory. It was hypothesized that emotional secrecy has a negative impact on (1) physical and (2) subjective well-being. Also, the study examined whether the relation holds when controlling for negative affectivity (NA), a variable that can be assumed to mediate the relation between emotional secrecy and physical and subjective well-being. Consistent with the hypothesis, emotional secrecy negatively affected physical health. This finding was not explained by NA, which contributed independently to physical health. Contrary to the prediction, emotional secrecy affected life satisfaction but indirectly through the mediating influence of physical health. The implications of these results for future research on emotional secrecy and physical and subjective well-being are discussed

Greenberg, L. S. and W. Malcolm (2002). "Resolving unfinished business: relating process to outcome." J Consult Clin Psychol 70(2): 406-16.  [PubMed]
This study related the process of the resolution of unfinished business with a significant other to therapeutic outcome in a population of 26 clients who suffered from various forms of interpersonal problems and childhood maltreatment. Clients were treated in emotion-focused, experiential therapy with gestalt empty-chair dialogues. Those clients who expressed previously unmet interpersonal needs to the significant other, and manifested a shift in their view of the other, had significantly better treatment outcomes. The presence of the specific process of resolution in the clients' empty-chair dialogues was also found to be a better predictor of outcome than the working alliance. Degree of emotional arousal was found to discriminate between resolvers and nonresolvers.

Kelley, J. E., M. A. Lumley, et al. (1997). "Health effects of emotional disclosure in rheumatoid arthritis patients." Health Psychology 16(4): 331-40.  [PubMed]
This study examined the effects of emotional disclosure of stressful events on the pain, physical and affective dysfunction, and joint condition of patients with rheumatoid arthritis (RA). Patients were randomly assigned to talk privately about stressful events (disclosure group, n = 36) or about trivial topics (control group, n = 36) for 4 consecutive days. Disclosure resulted in immediate increases in negative mood. At 2 weeks the 2 groups did not differ on any health measure, but at 3 months disclosure patients had less affective disturbance and better physical functioning in daily activities. There was no main effect of disclosure on pain or joint condition, but among the disclosure patients, those who experienced larger increases in negative mood after talking demonstrated improvements in the condition of their joints. This study concludes that, among RA patients, verbal disclosure and emotional processing of stressful life events induces an immediate negative mood followed by improved psychological functioning.

Murray, E. J. and D. L. Segal (1994). "Emotional processing in vocal and written expression of feelings about traumatic experiences." Journal of Traumatic Stress 7(3): 391-405.  [PubMed]
The purpose of this study was to compare vocal and written expression of feeling about interpersonal traumatic and trivial events in 20-min sessions over a 4-day period. Similar emotional processing was produced by vocal and written expression of feeling about traumatic events. The painfulness of the topic decreased steadily over the 4 days. At the end, both groups felt better about their topics and themselves and also reported positive cognitive changes. A content analysis of the sessions suggested greater overt expression of emotion and related changes in the vocal condition. Finally, there was an upsurge in negative emotion after each session of either vocal or written expression. These results suggest that previous findings that psychotherapy ameliorated this negative mood upsurge could not be attributed to the vocal character of psychotherapy.

Reis, H. T., K. M. Sheldon, et al. (2000). "Daily well-being: the role of autonomy, competence, and relatedness." Pers Soc Psychol Bull 26(4): 419-435.  [Abstract/Full Text] 
Emotional well-being is most typically studied in trait or trait-like terms, yet a growing literature indicates that daily (within-person) fluctuations in emotional well-being may be equally important. The present research explored the hypothesis that daily variations may be understood in terms of the degree to which three basic needs - autonomy, competence, and relatedness - are satisfied in daily activity. Hierarchical linear models were used to examine this hypothesis across 2 weeks of daily activity and well-being reports controlling for trait-level individual differences. Results strongly supported the hypothesis. The authors also examined the social activities that contribute to satisfaction of relatedness needs. The best predictors were meaningful talk and feeling understood and appreciated by interaction partners. Finally, the authors found systematic day-of-the-week variations in emotional well-being and need satisfaction. These results are discussed in terms of the importance of daily activities and the need to consider both trait and day-level determinants of well-being.

Smyth, J. M. and J. W. Pennebaker (2008). "Exploring the boundary conditions of expressive writing: In search of the right recipe." Br J Health Psychol 13(Pt 1): 1-7.  [PubMed]
This is a great introduction to the journals special section on "Boundary conditions of expressive writing" and its 19 associated articles.  What once appeared to be a straightforward intervention is turning out to be much more complex than initially thought.

Suls, J., P. Green, et al. (1997). "Hiding worries from one's spouse: associations between coping via protective buffering and distress in male post-myocardial infarction patients and their wives." J Behav Med 20(4): 333-49.  [PubMed] 
The relationship between protective buffering, a style of coping in which the individual hides his/her concerns from spouse, and level of distress was studied among post-myocardial infarction (MI) patients and their spouses. Forty-three male married MI survivors and their wives completed measures of psychological distress and protective buffering at 4 weeks and 6 months post-hospital discharge. At both time periods, a greater propensity for protective buffering by the patient was related to higher levels of patient distress. Protective buffering by wife was also associated with higher levels of wife distress. In addition, patient buffering at 4 weeks predicted increased patient distress at 6 months. The results suggest that male MI patients who conceal their worries from their spouses adjust more poorly over time.

I read a lot of research.  When I find an article of particular interest I download it to my bibliographic database - EndNote - which currently contains over 13,800 abstracts. 

Every few weeks I scan through all the articles I've found interesting in the previous month (in the general areas of stress, health & wellbeing) and then filter them into three narrower, more specific mailings.  One is to the communal email list of the British Association for Behavioural & Cognitive Psychotherapies (BABCP).  This set of abstracts focuses particularly on cognitive therapy in its many applications (anxiety, depression, psychotic disorders, etc).  Click on BABCP mailing to see the 30 papers (mostly from December journals) that I recently sent out.

A second mailing is to various people involved with Depression Alliance Scotland (DAS).  DAS is the only Scottish-based charity specifically working for people with depression who live in Scotland.  I've been on their Clinical Advisory Board for some years.  These abstracts focus more on depression and many are about antidepressant medication as well as others which overlap with the BABCP mailing on psychotherapy.  Click on DAS mailing to see the 17 papers recently sent out.

The third mailing is to the editor of the British Holistic Medical Association (BHMA) newsletter.  Back in the early 1980's I was on the working party that set up the BHMA.  I'm not much involved with them now - partly because many of their original objectives have been achieved and are now mainstream.  This month's BHMA mailing contains 30 abstracts covering the health effects of dietary factors - including lead, vitamin E, soya, folic acid, omega 3's & salt, health & wellbeing in NHS staff, perceived age, oxytocin & attachment security, ginkgo biloba & memory, erectile dysfunction & placebo response, housework participation & frequency of sex, and more.

I had an interesting mix of experiences yesterday.  It's left me wondering - about the balance between passion and peacefulness, about whether vitality and craziness fit into a meditative life, about courage and risk and exploration.

I play tennis - not very well.  I used to play quite a lot as a kid, and quite recently I've come back to it.  I often go to the Monday evening open "adult practice" sessions at the indoor courts less than a ten minute bike ride up the road.  I enjoy trying to play better.  I had a few individual coaching lessons last year and I find it fascinating how sometimes I can play reasonably well and sometimes it all falls apart.  For Christmas I asked for a copy of "The Inner Game of Tennis".  It was published in the 1980's, but you can still buy it new at Amazon and of the 18 customer reviews, 16 are "five star".  Interesting.  The book jacket reads: "The Inner Game of tennis ... takes place in our mind, played against such elusive opponents as nervousness, self-doubt and lapses of concentration ... peak performance at tennis, like any sport, only comes when our mind is so focused that it is still and at one with what our body is doing. The key to the "Inner Game" and better tennis is achieving this state of relaxed concentration so that we are playing "out of our mind" ... Tim Gallwey, a professional player and instructor who has produced dramatic results among the amateurs and pros he has trained, explores how to overcome mental obstacles, improve concentration and reduce anxiety for better performance at every level. There is no physical reason why any of us should not more consistently serve aces or hit perfect returns."

I know quite a lot about this stuff.  I teach and practise forms of relaxation and meditation, and have done for many years.  For example, yesterday afternoon at the dentist I declined anaesthetic injections (as I tend to) to explore more how the mind deals with anxiety and pain.  The friendly dentist said she wouldn't have undergone the procedure in this way.  I did have an out though - we'd agreed I could wave my hand at any time and we'd switch to anaesthetic!

So the "Inner Game" approach felt like it came pretty naturally - but it's also very different from the usual way I play sport.  I guess my roots go back to playing rugby for the various schools and colleges I attended.  I was pretty passionate.  At junior school we had boxing too, and I ended up as captain of our team, as I did at rugby.  I love "going for it" and, at racquet sports, I tend to be the noisiest person on the court.  My friends tell me it's fun!  I certainly enjoy it hugely.  So paradoxically - although an inner game meditative approach feels a familiar way to be - it doesn't feel familiar for me when I'm playing competitive sport.

Well, after one attempt at it, I would say it probably helped my tennis game.  The jury's out.  I plan to explore it more.  But the point of this story isn't just about tennis.  Afterwards I biked home through the icy, snow-filled streets.  Quite dangerous, but I was being careful.  I thought a little about the inner game as I cycled.  Observant.  Relaxed.  Suddenly, as I was coming quite fast down an icy hill, a big solid snowball flew out of the dark hitting me hard on the side of the throat.  Definitely dangerous.  A few inches higher and it would have hit me in the face.  I could easily then have lost control of the cycle.  Not good.

I came to a stop and headed back up the street.  I was angry.  The snowball had come from the side of the canal, an area now screened behind the end of a big hedge.  I didn't know who I would find in the dark or how many of them.  I guess I can be quite impetuous at times.  As I came round the edge of the hedge, I met a grinning teenager coming down the steps.  Maybe 16 years old.  A couple of other biggish lads with him, and an older woman.  I grabbed the collar of his coat and yelled.  Something about the danger and thoughtlessness of what had happened.  He and his mates looked quite shocked, making excuses, saying the snowball hadn't come from them.  I turned and left them.  Was what I did sensible?  Partly I wanted to make them think before they tossed a snowball at another cyclist who maybe wouldn't get away as lightly as I did.  But yelling didn't fit too well, it seemed, into my "inner game" meditativeness!

How do passion and peacefulness fit together?  Do they?  I want both in my life.  I have a dear friend who has meditated for decades.  In recent years he has practised even more intensively and teaches retreats.  I'm not sure that the way it affects him is all good.  There seems to be a cooling.  Sometimes I feel it makes him more withdrawn, less crazy, less passionate, less alive.  Who knows?  As I've written many times in this blog, mindfulness and relaxation can be hugely helpful.  However, as the fine meditation teacher Jack Kornfield has pointed out, these inner practices can also go out of balance.

So now, the next morning, what do I feel and think about the snowball episode last night.  It seems natural to me to experience anger when one is treated thoughtlessly and dangerously.  I don't have a problem with this.  It's a little dodgy in today's cities to head back to confront people, when one has no idea of who or how many they are.  I'm glad I had the courage to do it.  However I'm not so happy about yelling at them.  Throwing snowballs can be a lot of fun.  I don't now think they were being deliberately dangerous - probably more just thoughtless.  Maybe I would have been more memorable for them - made it less likely that they'd be that thoughtless again - if I'd simply and quietly explained that I was upset and why. 

I've done that before.  Years ago, while I was sitting unobtrusively meditating in a no-smoking railway carriage (before trains became all non-smoking) in came five or six quite drunk football supporters.  They were loud.  One of them was smoking.  Nobody in the carriage said anything.  The ticket collector came by, but he too didn't confront them.  They were big and sounded aggressive.  Who knows - maybe I was foolish, maybe not.  I was certainly very quiet and peaceful inside.  I walked up the carriage and squatted down beside the smoker.  I put my hand out to touch him lightly on the shoulder and said something like "I'd prefer it if you didn't smoke."  I got a mouthful of abuse, but I was very peaceful still.  I spoke again saying something like "I'm not trying to be aggressive.  Smoking bothers me.  That's why I'm in this carriage.  I'd be grateful if you didn't smoke."  And I then stood up and walked back to my place.  There was some loud discussion amongst the football supporters.  Then the guy who I think was probably their leader, stormed up the carriage with a cigarette packet in his hand shouting something to his smoking friend about throwing the packet out of the window.  No more smoking.  Quiet.  Interesting.

Hey, but a bit of passion, dance, wildness - they can be good too!