For many years I have run two kinds of "training group" for clients.  One teaches what can loosely be thought of as "stress management skills".  The latest version of this is the "Life skills for stress, health & wellbeing" course that I have been describing at some length in blog posts over the last three months.  The other kind of group that I regularly facilitate focuses on relationships.  As this group has evolved over the years it has been given various titles.  For quite some time I called it the "Relationships & emotional intelligence" group.  It was an accurate description of what we focused on, but it was kind of clunky as a label.  I've now reverted to simply calling the course "Opening up".  The publicity leaflet reads:

what is this course about?  This course is about relationships and emotional intelligence.  It involves working in a small group of 6 to 8 people (plus the facilitator Dr James Hawkins) over seven evenings and a full day session.  We will be looking at relationships in three areas - in the group itself, in our lives generally, and in our pasts.  The aim is to help us understand better and improve how we relate with others.    

why take time to look at relationships?  It's worth taking the time because relationships are such a huge part of our lives.  Past relationships deeply affect how we feel about ourselves and how we interact with others.  Current relationships can be a great source of joy, warmth and support, or of loneliness, frustration and unhappiness.  Human beings are social animals.  In many ways we are the sum of our relationships.  As adults, we don't have to just accept how we learned to relate when we were younger.  We can look at our interpersonal style and how we connect with our emotions.  We can get feedback from others.  We can decide what patterns we are happy with and what we'd like to improve on.  The group gives us the opportunity to do this and a chance to practise new ways of being with others.  We can change how  we are in relationships.  In doing so we change ourselves, our worlds, and the way we affect those around us.

how does working in the group help?  There are specific personal characteristics that are crucially important in allowing us to develop really nourishing relationships.  Our upbringing, education and society in general often actively inhibit this emotional intelligence.  With care, hard work and the right situation, these qualities can be encouraged to develop.  One of the mechanisms for this is by opening up.  The diagram below illustrates how feedback and self-disclosure can allow us to share more deeply, opening the ‘window', and providing us with a chance to learn and change.

The so-called "Johari Window" illustrates the way that being more genuine allows others to get to know us better, while feedback helps us to learn how we actually affect those around us - in Burns' words "O wad some power the giftie gie us to see oursels as ithers see us!  It wad frae monie a blunder free us, an' foolish notion."  The Johari diagram was developed by Jo Lufts and Harry Ingham many years ago and is a nice illustration of "opening up" (if you want a copy of the diagram, here are downloadable PDF and Powerpoint versions)

So yesterday was the first evening of the current "Opening up" course.  I went to my first interpersonal group - a weekend "Encounter group" - back in 1972.  It blew me away.  I just hadn't realized people could be so open and honest with each other.  I'd been brought up in a traditional, caring, good British family.  I kind of felt the world would fall apart, and the walls smeared with blood, if one allowed such open expression of feeling.  Not true!  I dived into this group therapy world and have a pretty huge experience of many different types accumulated over nearly forty years.  I can be a fairly questioning cerebral animal, and I've certainly done a good deal of reading and thinking about group processes.  I've run many groups and I train other therapists in these approaches as well - see for example the five day course scheduled to run for the University of Strathclyde/Caledonian University next March (pages 15 & 16 of their "Psychological therapies knowledge exchange programme").

What I'd like to do over the eight sessions of this "Opening up" group is jot down some thoughts and reflections triggered by the different meetings.  It's crucial that group participants feel as safe as possible in sharing personal material.  I get everyone to sign a "Confidentiality agreement" on joining the course and I'm certainly not going to use this blog post to share anything about the work of individual participants.  However reflection on the group is typically very useful, so I hope this series of general reflections will be helpful both for participants and would-be participants in "Opening up" groups - and for others who are interested in this format for therapy and personal growth.

The first session of a group can be quite challenging.  Preparation of participants before they even walk through the door is important - why is coming to this group personally relevant for them, in what way might the group be helpful, what is the group interaction likely to involve?  The American Group Psychotherapy Association website is a useful resource.  It has a publicly orientated "About group psychotherapy" section, and a more therapist orientated set of "Practice guidelines for group psychotherapy" with pieces on a series of topics including "Creating successful therapy groups" and "Preparation and pre-group training".  I wouldn't accept anybody onto an "Opening up" group if I hadn't already seen them one-to-one.  I have also sent out a set of handouts which include a couple I've particulary asked them to read before the first meeting - "Group therapy, background information" and "What it's usually helpful to talk about in the group".  Other handouts and pre-/post-assessment measures are listed in two previous blog posts - "Interpersonal groupwork 1" and "Interpersonal groupwork 2".

So we started with welcomes and gentle ice-breaking - an exercise in pairs "How did you feel coming to the group this evening?" with possible extensions into what this says about me more generally and the kinds of patterns I have relating with others.  I've been in a lot of groups where we all sat around in more or less frozen silence for quite a while before anybody said anything.  They have their value, but here in the "Opening up" group I'm strongly influenced by the early, and still relevant, findings on the kind of group facilitator style associated with better outcomes.  Key facts are illustrated by this six-slides-to-a-page Powerpoint handout - also available as a PDF handout.  These slides highlight particularly the importance of "caring" and of "meaning attribution" in how one facilitates groups.

A little later we moved on to a pair exercise exploring what each of us personally most want to achieve, or change, or learn more about in this group.  This was then distilled down into one or two key sentences and I wrote each person's intentions up onto A1 flipcharts which will remain visible throughout all future sessions of the group.  Participants may adapt or change their key intentions over the course of the group, but it can be very helpful continuing to relate what happens in the group to what each member particularly wants to be working on for themselves.  Plenty of friendly, opening discussion.  I sometimes see the early part of the group as constructing a safe enough, caring enough, strong enough "cooking pot" that will be able to contain the future group process as it heats up emotionally.  And finally in the last ten or fifteen minutes I ask everyone - including myself - to fill in a "Reflection sheet" (see too the related "Background" description).  Later in the week I will copy or scan the reflection sheets, and all participants get copies of all sheets in time to look through before the next meeting.  This can enrich the group and the learning process in all kinds of interesting ways.   A good first session ... the boat is leaving harbour ... 

Relationships are so important - whether we look at wellbeing & happiness, resilience under stress, or surviving to have a long, healthy life.  The diagram below is based on a series of studies that have been around for a while - Berkman & Syme's "Social networks, host resistance, and mortality", House et al's "The association of social relationships and activities with mortality", Welin et al's "Prospective study of social influences and mortality", Orth-Gomer & Johnson's "Social network interaction and mortality", Rosengren et al's "Stressful life events, social support, and mortality", and Olsen's "Impact of social network on cardiovascular mortality".  There's plenty of recent work showing similar patterns.  Biological, health behaviour, personality and health status variables do not explain away this association.  Social integration is as strong or stronger as a risk factor than smoking, high blood pressure, cholesterol & family history ... and social integration seems to be deteriorating due to changes in divorce rates, proportions of those who are old or living alone, city lifestyles, and so on.  

But it's not just about physical health & mortality - relationships are also so strongly connected with happiness & wellbeing.  Csikszentmihalyi & Hunter's "Happiness in everyday life: the uses of experience sampling" found highest levels of reported happiness when people were with friends.  Diener & Seligman's study on "Very happy people" reported how social happy people are.  And it's not just sociability, it's depth too.  Demir et al found that friendship variables (number, quality, personality, conflict) accounted for nearly 60% of variance in happiness, with friendship "quality" being of particular importance.  Similarly Reis et al's "Daily well-being: the role of autonomy, competence, and relatedness" reported that to satisfy relationship needs "The best predictors were meaningful talk and feeling understood and appreciated by interaction partners".  And in a study done this year - "Eavesdropping on happiness" - Mehl & colleagues used digital audio recorders to track real world behaviour and found that "The happy life is social rather than solitary, and conversationally deep rather than superficial".

With so much good evidence highlighting the huge importance of relationships, why not treat yourself to high quality time exploring these issues more fully?  There's a residential course this autumn that provides just this opportunity:

what is this course about?  This is a three day residential for those of us who would like to look more deeply at the crucial importance of friendship in our lives.  We'll explore four areas:  a.)  the fascinating, and growing evidence that friendship is such an important contributor to our physical mortality risk, to our psychological resilience, and to our well-being & joy in life. b.)  review how we've got to where we are - how our attitudes to friendship itself have evolved over our lives, and look at our past & present patterns in building relationships - exploring what obstructs & what nourishes how we are as friends. c.)  use practical exercises to chart our current friendship networks, and try out ways of working with conflict, building enjoyment, & deepening intimacy.  We'll aim to clarify our relationship needs more fully, and plan how we would ideally like our friendships to grow in the future. d.)  learn from the experiences of others in the group, including reflecting and sharing feedback on the here-and-now of our evolving group interactions.  Friendship is so important.  Pretty much all of us could enjoy and benefit from exploring how we want to nourish our friendships even better.

who will be there?  We plan to have up to 16 participants plus the 2 facilitators - James Hawkins & Larry Butler.  Larry & James have been friends for nearly 30 years  and have worked together over this time with a variety of interpersonal groups both in Scotland and in the UK more generally.  Larry was born in Illinois and has been living in Glasgow since 1981. His day job is teaching tai-chi in healthcare settings and leading life-story groups at the Maggie Cancer Care Centre. He is convenor for Lapidus Scotland: http://www.lapidus.org.uk/ and his current major project is creating an arts-eco village: http://www.bodhi-eco-project.org.uk/.  James is a medical doctor & psychotherapist.  He works in Edinburgh seeing clients on a one-to-one basis and running life skills and interpersonal groups, as well as providing education and training for other health professionals. 

course dates & location?  This is a three day residential group running from a shared supper at 7.30pm on Thursday evening 25^th until 3.00pm on Sunday 28th November.  We'll be staying at Stroove House, 38 Montgomerie Terrace, Skelmorlie, North Ayrshire, PA17 5DT.  Stroove -  www.ymcaglasgow.org/stroove.asp  - is on the coast between Greenock and Largs, less than an hour's journey by car or train from central Glasgow.  There are bus & rail links to Wemyss Bay which is close by.

For more information about the (extremely reasonable!) costs and enrolment, download fuller information as a Word file or a PDF.

Here are half a dozen recent research studies that caught my eye.  Diener et al, in a large sample of people round the world, found intriguingly that wealth tends to increase life satisfaction, while it is the fulfilment of psychological needs - learning, autonomy, using one's skills, respect, and the ability to count on others in an emergency - that better predicted positive feelings.  Quoidbach & colleagues took this a stage further showing that " ... money impairs people's ability to savor everyday positive emotions and experiences. In a sample of working adults, wealthier individuals reported lower savoring ability (the ability to enhance and prolong positive emotional experience). Moreover, the negative impact of wealth on individuals' ability to savor undermined the positive effects of money on their happiness".  Delightfully they reported "We found that participants exposed to a reminder of wealth spent less time savoring a piece of chocolate and exhibited reduced enjoyment of it compared with participants not exposed to wealth" - the practical advice you do get on this website!

Shifting to a couple of interesting recent studies on relationships with others, Kavanagh et al in their paper "The mating sociometer: a regulatory mechanism for mating aspirations" found a fascinating lack of connection between mating self-esteem and friendship self-esteem.  While Gilet et al in their study on "Selfish or servant leadership" - admittedly only in coordination game observations - commented "Our results support the evolutionary hypothesis that leadership is a social good for the group: leadership benefits followers but is potentially costly for the individual taking on the leader role. Across the two economic games leaders do less well - earn less money - on average than followers. Furthermore, social participants choose to lead more often than selfish participants and there is no relationship between leadership behavior and personal dominance".  As a rather impoverished extrovert, I'm not quite sure how to react to this report.

Finally there are a couple of studies on more intrapersonal issues.  Raes's paper "Rumination and worry as mediators of the relationship between self-compassion and depression and anxiety" reports that self-compassion's positive influence on psychological distress is partly mediated by its effects on unproductive repetitive thinking.  And Barber et al in  "Affect regulation strategies for promoting (or preventing) flourishing emotional health" highlight that " ... in order to achieve flourishing, individuals may need to reduce avoidance strategies and increase engagement strategies".  Both these papers add to other recent literature also demonstrating links between mindfulness, self-compassion & reduced depression, and between behavioural activation & increased wellbeing.       

Diener, E., W. Ng, et al. (2010). "Wealth and happiness across the world: material prosperity predicts life evaluation, whereas psychosocial prosperity predicts positive feeling." J Pers Soc Psychol 99(1): 52-61.  [PubMed] 
The Gallup World Poll, the first representative sample of planet Earth, was used to explore the reasons why happiness is associated with higher income, including the meeting of basic needs, fulfillment of psychological needs, increasing satisfaction with one's standard of living, and public goods. Across the globe, the association of log income with subjective well-being was linear but convex with raw income, indicating the declining marginal effects of income on subjective well-being. Income was a moderately strong predictor of life evaluation but a much weaker predictor of positive and negative feelings. Possessing luxury conveniences and satisfaction with standard of living were also strong predictors of life evaluation. Although the meeting of basic and psychological needs mediated the effects of income on life evaluation to some degree, the strongest mediation was provided by standard of living and ownership of conveniences. In contrast, feelings were most associated with the fulfillment of psychological needs: learning, autonomy, using one's skills, respect, and the ability to count on others in an emergency. Thus, two separate types of prosperity-economic and social psychological-best predict different types of well-being. 

Quoidbach, J., E. W. Dunn, et al. (2010). "Money Giveth, Money Taketh Away." Psychological Science 21(6): 759-763.  [Abstract/Full Text]
This study provides the first evidence that money impairs people's ability to savor everyday positive emotions and experiences. In a sample of working adults, wealthier individuals reported lower savoring ability (the ability to enhance and prolong positive emotional experience). Moreover, the negative impact of wealth on individuals' ability to savor undermined the positive effects of money on their happiness. We experimentally exposed participants to a reminder of wealth and produced the same deleterious effect on their ability to savor as that produced by actual individual differences in wealth, a result supporting the theory that money has a causal effect on savoring. Moving beyond self-reports, we found that participants exposed to a reminder of wealth spent less time savoring a piece of chocolate and exhibited reduced enjoyment of it compared with participants not exposed to wealth. This article presents evidence supporting the widely held but previously untested belief that having access to the best things in life may actually undercut people's ability to reap enjoyment from life's small pleasures.

Kavanagh, P. S., S. C. Robins, et al. (2010). "The mating sociometer: a regulatory mechanism for mating aspirations." J Pers Soc Psychol 99(1): 120-132.  [PubMed] 
Two studies (Ns = 80 and 108) tested hypotheses derived from Kirkpatrick and Ellis's (2001) extension and application of sociometer theory to mating aspirations. Experiences of social rejection-acceptance by attractive opposite-sex confederates were experimentally manipulated, and the impact of these manipulations on self-esteem, mating aspirations, and friendship aspirations was assessed. Results indicated that social rejection-acceptance by members of the opposite sex altered mating aspirations; that the causal link between social rejection-acceptance and mating aspirations was mediated by changes in state self-esteem; and that the impact of social rejection-acceptance by members of opposite sex was specific to mating aspirations and did not generalize to levels of aspiration in approaching potential same-sex friendships. This research supports a conceptualization of a domain-specific mating sociometer, which functions to calibrate mating aspirations in response to experiences of romantic rejection and acceptance.

Gillet, J., E. Cartwright, et al. (2010). "Selfish or servant leadership? Evolutionary predictions on leadership personalities in coordination games."  Personality and Individual Differences. In Press, Corrected Proof.
We study the personalities of emergent leaders in two coordination games in groups of four players each with monetary incentives. Our results support the evolutionary hypothesis that leadership is a social good for the group: leadership benefits followers but is potentially costly for the individual taking on the leader role. Across the two economic games leaders do less well - earn less money - on average than followers. Furthermore, social participants choose to lead more often than selfish participants and there is no relationship between leadership behavior and personal dominance. Our results support the idea that leadership can be servant rather than selfish and we note the implications of this finding.

Raes, F. (2010). "Rumination and worry as mediators of the relationship between self-compassion and depression and anxiety." Personality and Individual Differences 48(6): 757-761.  [Abstract/Full Text] 
The mediating effects of rumination (with brooding and reflection components) and worry were examined in the relation between self-compassion and depression and anxiety. Two hundred and seventy-one nonclinical undergraduates completed measures of self-compassion, rumination, worry, depression and anxiety. Results showed that for the relation between self-compassion and depression, only brooding (rumination) emerged as a significant mediator. For anxiety, both brooding and worrying emerged as significant mediators, but the mediating effect of worry was significantly greater than that of brooding. The present results suggest that one way via which self-compassion has buffering effects on depression and anxiety is through its positive effects on unproductive repetitive thinking.

Barber, L. K., P. G. Bagsby, et al. (2010). "Affect regulation strategies for promoting (or preventing) flourishing emotional health." Personality and Individual Differences 49(6): 663-666.   [Abstract/Full Text]
This study examined affect regulation styles that best discriminated among affectivity groups representing languishing, moderate, and flourishing emotional health. Using the Measure of Affect Regulation Styles (MARS; Larsen & Prizmic, 2004) with 380 undergraduate students, analyses revealed nine affect regulation strategies (i.e., understanding/analyzing feelings, making plans, talking to someone, doing something enjoyable, being grateful, alcohol use, caffeine use, treating oneself, and consulting an advisor/mentor) that significantly distinguished between languishing and non-languishing individuals (moderate and flourishing) and six affect regulation strategies (i.e., withdrawal, emotion suppression, keep to themselves, downward social comparison, eating something, and daydreaming) that significantly distinguished flourishing individuals from those with moderate emotional health. Significant differences between moderate and flourishing groups consisted of behaviors that 'prevented' rather than 'promoted' flourishing (e.g., behavioral and cognitive avoidance). These findings suggest that in order to achieve flourishing, individuals may need to reduce avoidance strategies and increase engagement strategies.

Yesterday I wrote a post "Disagreeing with Jamie Pennebaker - writing can help past, present & future concerns".  I ended it with the words "In tomorrow's post I'll argue that therapeutic writing (although not so much expressive writing) is also potentially beneficial when the focus is on positive experiences as well".  In his Manchester conference talk last month Jamie was very clear that writing was not therapeutically useful when the focus is on positive experience.  I assume that he meant that expressive writing with it's emphasis on writing "deepest thoughts and feelings" about a subject isn't useful.  I can't imagine that Jamie isn't aware of the extensive and growing research literature showing that other forms of writing definitely are helpful when the focus is on positive experience.  My concern is that he didn't make this clear in his lecture and that many of his audience will have gone away with the "expert's" words ringing in their ears and assume that writing about positive experiences should be avoided.  What a pity! 

In fact I would go further than just "forms of therapeutic writing focusing on positive experiences can definitely be helpful" to "forms of therapeutic writing can definitely be helpful when focusing on all three time periods - past positive experiences, current appreciations, and future imagined positive possibilities".  So writing can help with problems (as well as boosting wellbeing) across the top "positive" sections of the following diagram (as well as across the lower "negative" sections):  

I'll take these three upper sections in turn.  What evidence is there that a focus on past positive memories is therapeutic?  In an earlier post "Writing for health & wellbeing" I described Burton & King's 2004 research study "The health benefits of writing about intensely positive experiences" which instructed participants "Think of the most wonderful experience or experiences in your life, happiest moments, ecstatic moments, moments of rapture, perhaps from being in love, or from listening to music, or suddenly ‘‘being hit'' by a book or painting or from some great creative moment. Choose one such experience or moment. Try to imagine yourself at that moment, including all the feelings and emotions associated with the experience. Now write about the experience in as much detail as possible trying to include the feelings, thoughts, and emotions that were present at the time. Please try your best to re-experience the emotions involved.  (On the second and third days of writing, these instructions included the sentence, ‘'You may either write about the same experience as yesterday, or you may choose a new one.'')."  The abstract of this paper read "In a variation on Pennebaker's writing paradigm, a sample of 90 undergraduates were randomly assigned to write about either an intensely positive experience (IPE) (n=48) or a control topic (n=42) for 20 min each day for three consecutive days. Mood measures were taken before and after writing. Three months later, measures of health center visits for illness were obtained. Writing about IPEs was associated with enhanced positive mood. Writing about IPEs was also associated with significantly fewer health center visits for illness, compared to controls. Results are interpreted as challenging previously considered mechanisms of the positive benefits of writing."

This is still a blog post in the making.  See Tarrier's work, Positive Attachment memories, Savoring, the Life Highlights exercise, and Reminiscence Therapy. Come back in a few days and hopefully I'll have said more useful here!

I've already written a couple of appreciative posts about Jamie Pennebaker's fascinating talk at the BABCP Manchester conference - one on "Expressive writing & emotional suppression" and another on "Expressive writing & timing issues".  I'm now going to write a couple of posts disagreeing with points Jamie appeared to make in his talk - one on the limited time focus he seemed to suggest expressive writing is relevant for, and the other on his remark that it isn't helpful writing about positive experiences.  I say "Jamie appeared to make" because I don't actually believe he's unaware of these issues.  Unfortunately, I do believe many people attending this talk may well have gone away misunderstanding these two points - and they're important points. 

I very much respect Jamie Pennebaker's work and have done for many years.  He's a bit of a "hero" of mine.  However hearing him make the remarks he did about writing, time & emotional tone - and the remarks' possible effects on a large number of British psychotherapists - left me thinking about a much more severe example of "the expert" sometimes being believed ahead of the data.  Robert Koch was a great physician, awarded the Nobel Prize for identifying and describing Mycobacterium tuberculosis.  Sadly he didn't believe that bovine (cattle) and human tuberculosis were similar, which delayed the recognition of infected milk as a source of infection (condemning many people to preventable disease and death).  The message - good science can be viewed as the intelligent application of doubt; follow the data not the expert. 

So here's a diagram I've developed further from the one illustrated in my post on Emily Holmes's talk on imagery.  It's also downloadable as a PDF or Powerpoint slide.

The two "bones I want to pick" with Jamie's talk are the limited time focus that he suggested expressive writing is helpful for, and the limited emotional tone (just negative) he suggested writing in general is potentially helpful for.  I think some people will have left this talk thinking therapeutic writing is only relevant to the bottom left corner of the diagram (above) and not even the whole of this time section as Jamie had commented that the time to consider expressive writing is possibly weeks rather than days after an upsetting event.  I would argue strongly that research shows that expressive writing is applicable across the whole breadth - past, present & future - of negative, distressing experiences (although possibly it's best to avoid expressive writing in the first days after significant trauma).  In tomorrow's post I'll further argue that therapeutic writing is actually applicable across all six areas of the above diagram, and that good research shows benefit with focusing on past, present & future issues of both negative & positive emotional tone.  By therapeutic writing I mean all forms of writing that are being used for therapeutic benefit (to decrease distress and/or to increase wellbeing).  Therapeutic writing includes Jamie Pennebaker's expressive writing but also includes writing based on other underlying theoretical orientations such as affirmation theory, attachment theory, dissonance theory, aspects of positive psychology, and so on.    

In this post I want to highlight that research shows that Jamie Pennebaker's style of expressive writing is in fact applicable across the whole breadth of negative, distressing experiences - past, present and future.  As far back as 1998, Smyth - in his review "Written emotional expression: effect sizes, outcome types, and moderating variables" - noted "Whether participants were instructed to write about past, current, or past and current traumas was not related to the overall effect size".  Since then there have been a series of studies where participants have benefited from writing about a situation that they are still in at the time.  This research has involved cancer sufferers, people undergoing surgery, women with chronic pelvic pain, gay men facing prejudice, sufferers from organizational injustice, job loss and other groups.  Sometimes the expressive writing instructions have been slanted towards the "traumas" that initiated participants' current state, however in other research studies the instructions have clearly been broader and encouraged writing about all emotionally important aspects of their current difficulties.  In fact Jamie alluded to this in his talk, when he said "We now sometimes just ask people to write about something of personal emotional importance to them and find that it's about as helpful as asking them to write about their worst traumas".   

So research shows that expressive writing is relevant for both past "traumas" and also current distress.  As an aside I would comment that so-called posttraumatic symptoms seem to be common after many difficult life events, not just those we would typically classify as "traumatic" - see Mol et al's paper "Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study" for more on this.  Now there are also studies emerging showing the potential benefits of expressive writing for imagined difficulties in the future that haven't even happened yet!  So Dalton & Glenwick published a paper last year entitled "Effects of expressive writing on standardized graduate entrance exam performance and physical health functioning" and reported "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".

Great!  So the bone I've just picked was that I believe some people may have left Jamie Pennebaker's Manchester talk thinking that expressive writing was just relevant for past traumas (and even then only after a gap of some weeks).  Although I think there are genuine issues about not writing expressively too soon after traumatic experiences, it's clear that research highlights the potential value of expressive writing across the whole spectrum of past, present and even future difficulties.  A great tool to know about and to use for ourselves and - if we're therapists - for our clients as well.

In tomorrow's post I'll argue that therapeutic writing (although not so much expressive writing) is also potentially beneficial when the focus is on positive experiences as well.

I wrote yesterday about Jamie Pennebaker's talk at the Manchester BABCP conference and explored various issues including the importance of emotion regulation and the unhelpfulness of high levels of emotional suppression.  In today's post I would like to enlarge on the the important issue of timing and how the values of self-disclosure & expressiveness typically vary with how quickly one uses them after the event one is writing or speaking about - as well as mentioning a few other points Jamie made in his talk.  Seery et al's paper on 9/11 "Expressing thoughts and feelings following a collective trauma: immediate responses to 9/11 predict negative outcomes in a national sample" reported that "Contrary to common belief, participants who chose not to express any initial reaction reported better outcomes over time than did those who expressed an initial reaction. Among those who chose to express their immediate reactions, longer responses predicted worse outcomes over time".  This overlaps with research showing that "psychological debriefing" soon after trauma can actually be damaging.  See, for example, "Psychological debriefing for road traffic accident victims. Three-year follow-up of a randomised controlled trial" and "Emotional or educational debriefing after psychological trauma. Randomised controlled trial".  It further overlaps with the finding that degree of emotional arousal in the hospital casualty department after a road traffic accident contributes to the likelihood of later posttraumatic stress disorder - see "A prospective study of heart rate response following trauma and the subsequent development of posttraumatic stress disorder".  In other words, there may be more value in soothing & calming shortly after trauma rather than encouraging ventilation of feelings. 

I think it's important not to "over interpret" these time factor findings for expressive writing and psychological debriefing.  It would be easy to slip into believing that this research suggests it's best to "keep a stiff upper lip" after experiencing trauma.  I don't think this is necessarily the case.  There are major differences between telling a good friend or relative about one's recent experience of trauma and writing out the emotional details on a piece of paper or discussing the trauma in a room full of other traumatised people.  One way of highlighting this is to look at the situation through the lens of attachment theory.  When individuals are or have been severely threatened they may, very understandably, have care- seeking needs strongly activated.  See my blog post on "Behavioural systems: attachment (care seeking), care giving, exploration, sex & power" for more on this.  When care seeking attachment needs are activated our gut instinct is to look for responsive, loving, strong, soothing others who can help us - both emotionally and, if necessary, practically.  A cold piece of paper doesn't stroke our hair, tell us we're loved and of value, that it's going to be all right, that practical support is there when it's needed.  Soothing is typically the appropriate response to emotional care seeking.  Expressive writing acts by a cascade of effects but it doesn't give us a loving hug, do our shopping for us, or visit us in hospital.  Sometimes emotional upset is a social message to others and a drive to make contact with sources of security and reassurance.

Issues about timing of emotional expression fit too with Emily Holmes's work discussed in an earlier conference report.  Jamie Pennebaker alluded to these findings when suggesting that it was "probably bad to write much immediately after trauma" and - certainly in the first hours - likely to be preferable to distance oneself by engaging in other activities (preferably, Holmes would assert, activities demanding visuospatial processing).  Alternatively if one is going to engage in fairly immediate processing/talking about trauma, in the first hours it may be better to be quite analytical & cognitive rather than highly emotional in one's processing.  It's less clear what's most helpful in subsequent days, although Seery's paper (see above) gives us hints as too does Ginzburg's study on the benefits of repressive coping in the initial week after a heart attack.  Jamie suggested the time to consider expressive writing is possibly weeks rather than days later if one finds one is "thinking about it too much" and/or pushing others into compassion fatigue!  There are many studies showing expressive writing is helpful when writing weeks, months or years after traumas have occurred.  There are also studies showing benefits for writing about current stresses and it would be helpful to tease out whether any benefits of writing about one's current life situation (e.g. the challenges of starting college) occur more when facing general life stresses rather than when one is feeling particularly traumatised by one's situation (when other coping strategies  - like problem solving or seeking social support - might be better). 

Jamie also commented that he thought of expressive writing as a "life course correction" so he doesn't recommend writing regularly.  This is in contrast to less evidence-based approaches like the daily "morning pages" suggested in the popular book "The Artist's Way".  I guess one needs more specific research to test out who is right here - and under what circumstances.  Jamie commented one is likely to feel writing is helpful or not quite quickly.  I found it particularly interesting that he said that they now sometimes "just asked people to write about something of personal emotional importance, and that this seems about as helpful as writing about worst traumas".  This makes introducing expressive writing less daunting than the traditional "just jump right in and write your deepest feelings & thoughts about your worst life memories".  Also more recent is the finding that writing for 15 minutes three times with just a 10 minute break between writing episodes seems almost as helpful as spacing the writing episodes out daily or weekly.  In fact Jamie is now looking at writing for just 5 minutes three times with only a 3 minute break between writing episodes!  If you want to participate in an online research study about this visit the "Writing and health" section of his website and follow the link in "To try out the study go to http://www.utpsyc.org/Write."  Jamie has also been exploring "finger writing" (tracing the letters in the air rather than on paper) and talking into a tape recorder.  Both again seem almost as helpful as actual writing. 

Any other comments I noted?  Jamie said that reading what one has written out loud to others can be "a bad idea".  It may be better, if one is speaking about one's writing at all, to simply tell the other person about it rather than reading it verbatim.  This is an interesting comment that I heard with interest and caution.  When, as a therapist, I ask clients to do expressive writing as "homework", I regularly say to them that I want them to write very freely and honestly, so to do so knowing that they won't be expected to share what they've written with anyone else including me, the therapist.  When they bring the writing in to their next session, I check with them whether they'd like me to read any or all of it, or if they would like to read out or tell me about what emerged.  I say somewhat similar things when I give writing as an exercise in groups.  In highly disclosing interpersonal groups I often find that some of us do read out directly what we've written and this can be absolutely fine.  It depends on one's personal experience & style, as well as on the type of relationship one has with one's "audience".  I do underline though that it's crucial that one feels free to write with deep honesty, so to share the writing or not is secondary to wanting to support a very open, authentic exploration. 

Jamie Pennebaker also commented that expressive writing acts by a "cascade" of mechanisms.  He mentioned emotion-relevant theories (not venting or catharsis), cognitive theories (building a new story, finding meaning, changing perspective), and social processes (pre- to post-conversation changes).  He encouraged people exploring the value of expressive writing to be "open & playful" and gave links to his website and to some online writing & other questionnaires.

We then moved on to questions and Jamie made the unfortunate remark that writing was best kept for negative experiences rather than positive ones.  Maybe this is true for expressive writing, but it certainly isn't true for therapeutic writing more generally.  I'll look at this more fully in tomorrow's post.  Overall though a good, stimulating, interesting talk - well worth going to.

I've already written a series of five blog posts about the British Association for Behavioural & Cognitive Psychotherapies (BABCP) conference in Manchester last month.  One of the plenary presentations I went to was given by Jamie Pennebaker who spoke about "Expressive writing in clinical practice".  The entry on page 28 of the "Conference abstracts" book was pretty brief, just saying: "Writing about emotional upheavals in controlled experiments tends to improve physical and emotional health.  How do the research findings generalize to real world clinical practice?  Drawing on recent studies on writing and natural language use, a number of recommendations will be suggested concerning who should write, when the writing should be done, how the writing samples should be treated, and ways to think about writing as homework or direct boost to therapeutic sessions".

I like Jamie Pennebaker.  I like the body of research on expressive writing that he's done stretching back 25 years.  I like his style too.  I've heard him lecture two or three times and chatted with him.  Quite laid back, not dogmatic or prescriptive.  I've written quite extensively on this website about therapeutic writing.  See, for example, the three posts from this January on "Writing (& speaking) for resilience & wellbeing", last year's post "Writing for health & wellbeing", and the post from earlier this week on teaching therapeutic writing for the "Life skills" evening class that I run.  Clicking "writing" in the tag cloud will pull out a fuller listing of relevant material on this site.  I wondered if it was worth my while going to this talk, because I'm already familiar with this research area.  I'm glad I did.  I was struck particulary by a couple of areas - 1.) Some new developments & comments about Pennebaker's expressive writing work.  2.)  Disagreement with Jamie Pennebaker's throw away remark that it's not therapeutically worthwhile to write about positive experiences (and some thoughts about trusting "data" before "heroes"!).  

So firstly 1.) Some new developments & comments about Pennebaker's expressive writing work.  Here are a series of jottings I made as Jamie was lecturing.  There are now about 250 research articles on expressive writing.  Overall effect sizes are modest but consistent at about 0.2.  A point I have heard Jamie make in a previous lecture is that the typical effect size achieved in research on expresssive writing has decreased over the years.  For example, Joshua Smyth in his important 1998 paper "Written emotional expression: effect sizes, outcome types, and moderating variables" reported a considerably bigger average effect size of 0.47 which he commented "suggest that the effect of the writing task is similar to that found in other quantitative analyses of psychological interventions".  Why might effect sizes in more recent studies on expressive writing be less than those found in earlier studies?  Possible causes might be initial researcher allegiance effects or improved later research methodology or - and I've heard Jamie musing about this - maybe self-disclosure is more a part of normal U.S. cultural behaviour than it was in the 1990's so that the comparison control groups are now getting a bit of "expressive writing/expressive talking" themselves.  To use an antibiotic parallel, maybe current expressive writing research is not so much a comparison between penicillin or no penicillin as a comparison between a moderate dose of penicillin and a smaller dose of penicillin.  

This leaves me wondering if some cultures - and types of people - might benefit more from expressive writing than others.  Jamie has produced evidence showing that northerners may be less emotionally open than southerners, so maybe I should particulary be pushing the value of expressive writing here in Scotland!  He also, in this Manchester talk, mentioned two research studies - involving military personnel and college students - trying to help couples with adjustment difficulties.  In both cases apparently benefits were obtained when the male of the couple did the expressive writing but not vice-versa.  Difficult.  Other studies have shown no gender difference in how much people benefit from this kind of intervention.  Maybe culture & gender (& even age) are just hints about whether someone might be vulnerable to an over-repressive style.  There is good work showing that emotional suppression comes at a cost and that expressive writing, for example, can be of particular value for people who ruminate a lot and for those scoring high on suppression as indicated by responses to the "Emotion Regulation Questionnaire".  You can click through, as well, to a handout giving scoring & background details about this questionnaire and variation in typical suppression scores by gender & age.  See previous blog posts too on work from "Oregon university" and "Stanford psychophysiology lab" with their focus on this fascinating emotion regulation area.     

See tomorrow's post for more on Jamie Pennebaker's talk .

I wrote yesterday about the first part of this tenth "Life skills" evening.  I particularly discussed development of Goodwill practice - very much in the "Nourishing positive states" section of the "Four aspects" diagram (below).  In the second half of the evening we moved on to the "Exploring & processing" section of the diagram with the introduction particularly of various forms of therapeutic writing.

I'm a big fan of Jamie Pennebaker's work on the value of "expressive writing".  See for example the three blog posts I wrote back in January on "Writing (& speaking) for resilience & wellbeing".  For many years, "expressive writing" - delving deeply into feelings & thoughts about upsetting experiences - was the only form of "therapeutic writing" that one could validly claim had been shown to be of real use in good research studies.  This situation has now changed and continues to evolve excitingly.  Different research teams have now explored therapeutic writing that focuses on many different areas.  Examples include "best possible selves", "intensely positive experiences", dissonance between behaviour and values, growth after trauma, self-transcendence, attachment, personally respected qualities, and important life domains.

In early therapeutic - typically "expressive" - writing studies, participants were usually asked to write for 20 minutes or so on three or four consecutive days.  These instructions have now been widely varied, with writing time being anywhere between 2 and 30 minutes (or more), and intervals between writing sessions varying between a few minutes to over a week.  Gains have been surprisingly robust despite these variations! 

This evening's course participants were given a series of handouts about therapeutic writing.  One entitled simply "Therapeutic writing exercises" gave ideas for five "positive" writing topics.  These included looking at the possibility of "Posttraumatic growth", a couple of topics (personal values & important life domains) taken from self-affirmation theory (although other researchers have alternative more self-transcendent explanations for some self-affirmation gains), and a couple (best possible selves & intensely positive experiences) that I described last year in the blog post "Writing for health & wellbeing".  There's now a five week gap before the next "Life skills" evening, and I've asked course members to experiment with writing about at least a couple of these five "positive" topics.  

I also gave them handouts on Jamie Pennebaker's "expressive writing".  These included one written by me, and a series of slide miniatures (slides 1-6 and slides 7-12) giving a more academic view of the "expressive writing" research underpinnings.  Pennebaker's website gives further information and writing suggestions.  I have asked participants to also try out "expressive writing".  Traditionally this has involved writing for 15 to 20 minutes on three or four occasions, expressing one's deepest thoughts and feelings about the worst experiences of one's life.  It is rather "diving into the emotional deep end", although research shows this is a surprisingly safe and very frequently a helpful thing to do.  More recently I heard Jamie Pennebaker saying (at the BABCP conference last month) that it's now been found that simply writing one's "deepest thoughts and feelings" about "something of personal emotional importance" produces very comparable benefits.  So it's fine to choose challenging personal subjects from the past, present or even the future.  Writing about "positive" experiences should probably best be less analytical and more visual/sensory (involving the right hand side of the diagram below), while writing about "negative" experiences is probably best a mixture of delving deeply into emotions but also one's thoughts as well (so adding the left side of the diagram).  My recent blog on Emily Holmes's work discusses this and it's illustrated below:

Forms of therapeutic writing about both "positive" and "negative", or more accurately "pleasant" and "unpleasant", subjects are often helpful for our health & wellbeing for months after a series of three or four writing episodes.  Writing about "unpleasant" subjects may be particularly useful for people who tend to worry or ruminate a good deal.  Therapeutic writing is a great tool to have in one's "kitbag" of self-help methods. 

If you want others to be happy, practise compassion.  If you want to be happy, practise compassion.    Dalai Lama 

We had the tenth session of this "Life skills" course last night.  There had been a three week gap since the ninth meeting, and there will now be a five week gap until the eleventh, and a further eleven weeks until the final, twelfth meeting.  We began with a combined Autogenics plus Goodwill practice - downloadable recordings of these Goodwill meditations are findable further down the  the "Compassion & criticism" page of this website.  Participants had their usual handout of a dozen slide miniatures covering the material we were to explore.  See slides 1-6, Powerpoint or slides 1-6, PDF and slides 7-12, Powerpoint or slides 7-12, PDF. 

We began with a guided relaxation/meditation practice - on this occasion involving the full Autogenic Training sequence followed by the full Goodwill Practice.  We then went round checking how course participants had been doing with these exercises over the previous three weeks.  One of the interesting themes that emerged was how important (or not) it is to experience emotional/physical feelings when working with the Goodwill practice.  In some ways this discussion seems to parallel a similar set of questions that can emerge when people are first learning Autogenics or other forms of relaxation/meditation. 

My clinical experience is that people who "feel nothing/no change at all" when they practise relaxation, are probably unlikely to persist with or benefit from the practice.  The "Relaxation response" diagram, that I show people on the first evening of the course, highlights the quite profound physical changes that occur when someone quietens and relaxes deeply.  If someone "feels nothing" when they try to relax, then they may be relaxing but not noticing the internal changes that are occurring.  It seems more likely though that they are currently simply not relaxing very well.  A metaphor I sometimes use to describe working with this initial difficulty is of driving a wedge into a log of wood.  I say that they are first likely to begin noticing some physical/psychological feelings of relaxation under very easy conditions - for example, on a day that is going well, in a peaceful, safe situation, when their mind isn't too distracted - then when they try a relaxation exercise they may get some initial experiences of a pleasant comfortable state.  The aim is to gradually "drive the wedge in deeper", so that they slowly learn to elicit these (and deeper) relaxation feelings under progressively more difficult conditions e.g. when they are feeling stressed, when the outer environment is more noisy, when they are moving around, and so on.  I often draw a parallel with learning any other skill - for example, learning to drive, or type, or swim, or even learning to walk.  The "What progress can you expect?" handout makes these points in more detail.  

My sense is that this parallels changes that can occur with Goodwill, Loving-Kindness, and Compassion meditation practices (these three terms are pretty much synonymous).  So several course participants this evening commented on not feeling any physical changes or emotions when working with the Goodwill practice.  I am however pushing for the practice to involve emotion and not just a set of thoughts.  Emotions are very physical things.  They changes the landscape of the body - heart, lungs, blood distribution, muscles, viscera - via both chemical messages in the blood stream and electrochemical messages in nerve pathways.  Emotions also change the way the brain acts - how it pays attention, processes information, and readies the individual for specific kinds of action.  See the two "What do emotions do?" slides for more on this.  See too the recent Journal of Neuroscience paper "Opposing influences of affective state valence on visual cortical encoding" showing how different emotional states literally change what we see, and there's Hutcherson et al's research paper "Loving-kindness meditation increases social connectedness" showing that " ... even just a few minutes of loving-kindness meditation increased feelings of social connection and positivity toward novel individuals ... "  Imagining and feeling into experiences of goodwill/loving-kindness/compassion does produce very real changes in the body and mind.  See the two "Moods affect us quickly & powerfully" diagrams. 

It's a fascinating area.  One helpful lens through which to view this Goodwill work is the literature on adult attachment and caregiving.  Mikulincer & Shaver have written a chapter on "Adult attachment and caregiving: individual differences in providing a safe haven and secure base to others" in the currently "in press" book by Brown et al "Self-Interest and Beyond: Toward a New Understanding of Human Caregiving".  They write "The second of these behavioral systems (after the attachment/careseeking system), caregiving, was hypothesized by Bowlby to be the motivational heart of a parent's (or other adult's) response to a child's distress or need for support or assistance. In our opinion, this system is also the core of all empathic, compassionate reactions to another person's needs. It presumably evolved originally because it increased "inclusive fitness" by enhancing the survival of multiple others with whom a person shared genes, but it is a capacity that can be extended by social learning".  I wrote last month about how our behaviours and warmth can become a self-fulfilling prophecy - see, for example, Srivastava & colleagues' "Optimism in close relationships: How seeing things in a positive light makes them so", Assad et al's "Optimism: an enduring resource for romantic relationships", Klapwijk & Van Lange's "Promoting cooperation and trust in "noisy" situations: The power of generosity", Stinson et al's "Deconstructing the "reign of error": interpersonal warmth explains the self-fulfilling prophecy of anticipated acceptance" and the whole thrust of Crocker's fine work at her "Self and social motivation lab".  Goodwill practice is relevant to all of this.  We need to maintain authenticity.  This isn't about becoming "sugary".  But as Paul McCartney put it - with what John Lennon apparently said were the best lyrics Paul had every written - "In the end the love you take is equal to the love you make".   

I'll post again tomorrow about the second part of this tenth "Life skills" session.

I wrote a couple of days ago about Marylene Cloitre & colleagues's recent research paper "Treatment for PTSD Related to Childhood Abuse: A Randomized Controlled Trial", and yesterday I explored three questions that had struck me on thinking about this work - about the applicability of this approach to other (non child abuse) sufferers from complex PTSD, about the overlap with treatments for borderline personality disorder, and about the relatively brief duration of Cloitre's 16 session intervention for people suffering from such difficult symptoms. 

In today's third and last post about Cloitre's work, I want to think a little more around three further questions that I was struck by - 4.) What is involved in her skills-training module (an adaptation of dialectical behaviour therapy) and are there lessons here for other patients?  5.)  Arntz talks about the "limited re-parenting" involved in his work.  Cloitre discusses attachment issues and the importance of the therapeutic alliance.  Are there lessons here?  6.)  Was Cloitre's trauma processing treatment component as good as it could have been e.g. comparing it with Ehlers & Clark's version of trauma-focused CBT? 

So firstly - 4.) What is involved in her skills-training module (an adaptation of dialectical behaviour therapy) and are there lessons here for other patients? In their recent research paper, the STAIR - skills training in affect & interpersonal regulation - component of the treatment is described as follows: "The skills training interventions are adapted from dialectical behavior therapy. The first four skills sessions concern emotion regulation and focus on identifying and labeling feelings, emotion management, distress tolerance, and acceptance of feelings and experiencing positive emotions. The next four sessions concern interpersonal problems and focus on exploration and revision of maladaptive schemas, effective assertiveness, awareness of social context, and flexibility in interpersonal expectations and behaviors."  Marsha Linehan's 1993 book on dialectical behaviour therapy (DBT) "Cognitive-Behavioral Treatment of Borderline Personality Disorder" is specifically cited.  This is very broad brush.  From my point of view, there are a whole series of psychotherapy approaches for "affect & interpersonal regulation" (some examples include ACT, Emotion-Focused Therapy, Schema-Focused Therapy, DBT, and Compassionate Mind Training).  Particularly as one moves from research on the treatment of specific conditions to broader, less diagnosis-linked interventions, it becomes increasingly difficult to make strong evidence-based claims for one approach over another.  However DBT derived treatments are certainly worth looking at respectfully.

Moving on - 5.)  Arntz talks about the "limited re-parenting" involved in his work.  Cloitre discusses attachment issues and the importance of the therapeutic alliance.  Are there lessons here?  Fascinating territory.  I've written a good deal about attachment in this blog.  See, for example, "Attachment, compassion & relationships" and "Our life stories: needs, beliefs & behaviours".  Cloitre has published very interesting work in this area.  Papers include "Attachment organization, emotion regulation, and expectations of support in a clinical sample of women with childhood abuse histories" and "Therapeutic alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder".  The latter paper's abstract reads "This study examined the related contributions of the therapeutic alliance and negative mood regulation to the outcome of a 2-phase treatment for childhood abuse-related posttraumatic stress disorder (PTSD). Phase 1 focused on stabilization and preparatory skills building, whereas Phase 2 was comprised primarily of imaginal exposure to traumatic memories. Hierarchical regression analyses indicated the strength of the therapeutic alliance established early in treatment reliably predicted improvement in PTSD symptoms at posttreatment. Furthermore, this relationship was mediated by participants' improved capacity to regulate negative mood states in the context of Phase 2 exposure therapy. In the treatment of childhood abuse-related PTSD, the therapeutic alliance and the mediating influence of emotion regulation capacity appear to have significant roles in successful outcome".  So there are indications that a strong therapeutic alliance is helpful through improving patients' capacity to regulate negative mood - to self soothe better.  Sounds like attachment territory to me.

And lastly - 6.)  Was Cloitre's trauma processing treatment component as good as it could have been e.g. comparing it with Ehlers & Clark's version of trauma-focused CBT?  In their recent 2010 paper, Cloitre et al write "In this study, the exposure treatment followed the prolonged exposure protocol, with the following two modifications for the study population: 1) in vivo exposure to trauma stimuli was replaced with interpersonal skills practice, and 2) meaning analysis was introduced after the exposure in which abuse-related schemas embedded in the trauma narrative were identified and evaluated. Exposure included narratives of both childhood and adulthood traumas, reviewed in order of distress rating and importance to the participant".  They cite Foa et al's 2008 book "Effective treatments for PTSD".  Sounds good.  In their recent paper "Do all psychological treatments really work the same in posttraumatic stress disorder?", Anke Ehlers et al write about the "significant increases in effect sizes of trauma-focused cognitive behavior therapies over the past two decades".  Cloitre's approach looks good and evidence-based and - like all our work - can no doubt evolve further.  My hunch is that it could learn usefully from the Ehlers & Clark approach, but I suspect we're talking about only minor increases in effectiveness over what is clearly already an effective version of trauma-focused cognitive therapy.

Overall, Marylene Cloitre and colleagues' research is an admirable further step in improving therapy for adult survivors of child abuse and for complex PTSD.  I for one want to learn from their addition of affect & interpersonal skills training and from their emphasis on the importance of the therapeutic alliance in helping clients develop improved affect regulation.