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Finding a voice: revisiting the history of therapeutic writing
  1. A D Peterkin1,
  2. A A Prettyman2
  1. 1
    Department of Psychiatry, Mount Sinai Hospital, Toronto, Ontario, Canada
  2. 2
    Department of Philosophy, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Miss A A Prettyman, Department of Philosophy, University of Toronto, 170 St. George Street, Toronto, ON M5R 2M8, Canada; adrienne.prettyman{at}utoronto.ca

Abstract

We review the history of therapeutic writing, focusing on the role of narrative competence and the use of writing therapy for stress, trauma and coping with chronic illness. After providing a historical overview of the evidence for writing’s positive effects on health and the hypothesised mechanisms underlying this effect, we ask whether narrative competence can explain and improve writing’s benefit. Narrative competence is defined across two dimensions: (1) Emplotment, or the ability to construct and comprehend goal-oriented connections among temporally situated events; and (2) Meaning, or the ability to understand and communicate contextual interpretations of ambiguous story structures. We suggest that the ability to construct well-organised and meaningful narratives is an important skill for successfully coping with life stressors and trauma, enabling individuals to create coherent stories from fractured memories and to facilitate cognitive processing of traumatic events. Given the positive effect of narrative competence on psycho-physical health, there is a need to broaden medical use of narrative competence therapies beyond the current interventions aimed at fostering empathy among healthcare providers, to include therapies for the patients themselves. Toward this end, we briefly explore one clinical model currently offered by Dr Allan Peterkin and colleagues at Mount Sinai Hospital providing group Narrative Competence Psychotherapy (NCP) for individuals living with HIV.

  • narrative medicine
  • therapeutic writing
  • HIV/AIDS

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Words and magic were in the beginning one and the same thing, and even today words retain much of their magical power. By words one of us can give to another the greatest happiness or bring about utter despair, by words the teacher imparts his wisdom to the student…

– Sigmund Freud, from The interpretation of dreams

Writing allowed me to expand my own story—I’m not just somebody living with HIV…

– Anonymous member, Mount Sinai Hospital Narrative Competence Psychotherapy Group

Therapists have long invoked the power of words as a tool for helping clients to achieve psychological wellbeing. The question of whether this power to bring about therapeutic change extends to the written word is one that has only recently begun to occupy a place in psychological theory and practice. Evidence from empirical and qualitative studies supports a positive impact of expressive writing in many domains of physical and psychological health, particularly following trauma.1 These benefits may be especially pronounced when the expression of a stressful event is constrained by social stigma, for example, in the case of individuals living with chronic illness like HIV/AIDS.2 3 4 Evidence for the therapeutic benefit of writing has contributed to an understanding of narrative competence, in which individuals foster the ability to acknowledge, absorb, interpret and act in response to written works.5 A fundamental question arises from this ever-growing literature: can narrative competence be improved, and how might such improvements precipitate better physical and psychological health? While the term “narrative competence” has recently been used by Rita Charon5 to describe reflective attributes in clinicians, the concept of narrative competence extends beyond its application clinical contexts. Use of the term in this paper refers to autobiographical competence on the part of patients or clients who write as part of their self-reflection, healing or recovery. After tracing the history of therapeutic writing and exploring theoretical possibilities for the mechanism of writing’s effect on health, we briefly discuss a new extension of group therapy, Narrative Competence Psychotherapy, through a case study and feedback from individuals living with HIV/AIDS.

From life narratives to therapeutic writing

Definitions of narrative

What do we mean by “narrative”? Many theorists point to the act of emplotment as the common element that unites a diverse range of narrative expressions across cultures and history, from movement and dance to written prose. In a tradition that literary theorists trace back to Aristotle’s Poetics, narrative is defined as a representation of a causally connected sequence of events with a beginning, middle and end.6 7 8 9 10 For example, Riceour11 defined narrative as a temporal ordering of events in a causal sequence, arguing that narrative construction is inextricable from the phenomenal experience of time and mimesis. Integrating this notion of emplotment (as opposed to description of events) with insights from postmodernism, Dobson12 noted that good narratives are typified by multi-temporal (incorporating backwards or forwards temporal linking between events), multi-punctual (influenced by several different sources) and multi-accented (integrating different voices and perspectives) connections between events. Other theorists have developed the definition of emplotment to include the use of goal-directed action aimed at the resolution of a problem.13 14 Some have further invoked the universality of plot structures across cultures to support the thesis that narrative capacities are a crucial cognitive development in human evolution, particularly for transmitting information across generations.15 16 17

Life narratives and trauma

Relating these investigations in literary theory to our present focus on writing and therapy, we might think of narratives as representations of causally connected events that provide the context for framing and interpreting experience.18 In his early work on life narratives, White19 wrote that behaviour is a form of authoring oneself. In other words, following in the spirit of Riceour, narrative therapists see stories and experience as reciprocally constitutive. Narratives give meaning to decisions and actions, while at the same time, interpretations of decisions and actions underlie the life narrative.20 White’s Narrative Therapy, a form of individual talk psychotherapy, focuses on helping clients re-script their life narratives as new insights emerge. Narrative psychotherapies that illuminate the construal of self, others and the situation may enable individuals to construct and enact more adaptive life narratives, providing coherence to the many disjointed experiences constituting the life story by integrating them into a meaningful context.18 21

This process may be particularly helpful when traumatic or stressful experiences, including loss, disrupt the life narrative by interfering with psycho-physiological coordination, cognitive processes and social connections, making integration of these experiences into the life narrative more difficult. The result is narrative incompleteness or fragmentation surrounding the sense of self and placement in the social world.22 French psychiatrist Pierre Janet23 was perhaps the first theorist to suggest that the construction of a narrative that incorporates fragmented memories following trauma could militate the negative effects of such experiences. He noted that traumatic memories often take the form of disjointed sensations, an observation recently supported by neurological studies in the cognitive processing of trauma.

Some research on long-term memory formation supports this view. In one theory, memory formation involves coordination among modular systems of cognitive, emotional and autonomic processing in the human brain. In the event of trauma or stress, visual and emotional stimuli may bypass cognitive processing, resulting in memories that are more emotionally vivid and less well integrated than ordinary memories.24 In support of this theory, Cahill and McGaugh25 found that administering the beta blocker propanolol significantly impaired subject’s memory of emotionally evocative stories, but not of neutral stories. Van der Kolk26 likewise demonstrated that recall of traumatic memories is associated with atypical patterns of brain activity. Subjects in van der Kolk’s study reported difficulty providing a verbal account of their traumatic experiences, perhaps due to the separation of affective and sensory impressions from higher cognition in psychological processing of stressful experiences. As MacCurdy24 notes, verbalising or re-narrating fragmented traumatic experiences may help to combine “affect with cognition, image with narrative” following stressful experiences.

Writing and health

While one branch of narrative therapy has focused on psychotherapy as means to integrating traumatic memories into a coherent and complete narrative, another examines the use of therapeutic writing. Although distinct, these methods are often employed as complements: when an individual is reluctant to access psychological disturbance, story-writing can provide the vehicle to contact, reflection and catharsis in psychotherapy.27 Studies on expressive writing support the view that writing about stressful events increases positive psycho-physical outcomes, although researchers are less united in explaining the mechanisms that underlie this effect—partially as a result of the diversity of outcome measures employed to assess writing’s effects.28 29 Beginning with Pennebaker and Beall,30 empirical research provides pervasive support for the hypothesis that writing about stressful events rather than more “neutral” subject matter is associated with both an immediate increase in negative affect, and positive long-term health effects. Research interest in the use of writing began with Pennebaker and Beall’s early study of 46 undergraduate psychology students randomly assigned to write about either a personal trauma or a trivial topic over four consecutive days. The two writing conditions were compared on measures of short-term physiological functioning and frequency of health centre visits for six months following the writing task. In support of Pennebaker and Beall’s hypothesis that written expression of traumatic experiences facilitates cathartic contact with traumatic memories, students who wrote about a traumatic experience had higher blood pressure and more negative mood immediately following the exercises, but fewer health centre visits at six month follow-up than students who wrote on trivial topics. The significant effect of writing on health demonstrated by Pennebaker and Beall’s study incepted a flurry of interest in the therapeutic use of writing, leading to more precise understanding of writing’s relationship with health.

While individuals with physical or psychological disorders may require longer and more structured writing programmes to exploit their full health benefits31 numerous studies among “normal” and “symptomatic” populations have replicated Pennebaker’s early finding that writing about trauma is correlated with immediate arousal of negative feelings, followed by benefits in psychological wellbeing, physical health and general functioning at 1–6 month follow-up.2 For example, studies demonstrated that people who wrote about trauma had fewer physician visits,32 33 more positive affect and self-esteem,34 35 36 37 38 better immune functioning,31 39 40 41 faster re-employment following job loss42 and improved personal relationships43 44 compared to people who wrote on non-stressful topics. More recent work suggests that expressive writing may be cardioprotective through lowering blood pressure, may enhance health-related quality of life in cancer-survivors and is a low cost intervention that is self-directed and can be applied in group therapy settings and through new technologies including the internet.1

While a substantial body of research supports the therapeutic use of writing, not all people who write experience positive health outcomes. Some theorists have contested that narrative models of wellbeing may inappropriately restrict the range of healthy strategies different people employ in meeting trauma, stress, and the daily challenges of everyday life.45 Others have questioned the assumption that fewer health visits is an indicator of improved health, pointing to the importance of appropriate healthcare utilisation for maintaining physical and psychology wellbeing.46 To better assess how writing tasks should be used to help individuals cope with stress and trauma, researchers have examined factors that may contribute or detract from writing’s benefit. Meta-analyses evaluating the efficacy of therapeutic writing interventions among non-clinical populations have shown that men benefit more from writing tasks than women, longer term writing tasks produce more sustained benefits than briefer interventions, writing about recent trauma is more beneficial than writing about past stressors, and that subjects whose initial writing tells a coherent and resolved story are less likely to benefit.2 41 47

Studies examining the effects of writing interventions in clinical populations have also produced mixed results. While Klapow et al48 found that written self-disclosure reduced the cost of outpatient services for older primary care patients, they also found that subjects experienced no significant reduction in symptoms. Likewise, Harris et al49 demonstrated that written emotional expression had no effect on the disease status of asthma patients. It remains to be determined whether the lack of a positive effect of writing on health outcomes in clinical populations is due to the nature of the writing task involved, or whether some clinical populations benefit from writing more than others.50 Although not all studies confirm the salubrious effects of writing,37 51 52 53 the accumulating body of controlled studies, meta-analyses, and use of clinician ratings or objective health indices indicate the need for more research on the impact of therapeutic writing for physical and psychological health following stressful experiences, including chronic illness.

Therapeutic writing and self-help

Even before research studies confirmed the helpfulness of writing about thoughts and feelings, the self-help movement and numerous trade books announced the “writing cure”. Furthermore, growth of popularity of the internet over the last 10 years has led to online journaling or “blogging”, virtual writing support groups and an ever-increasing sharing of illness and trauma narratives. Several common themes and approaches emerge in these more popular applications of therapeutic writing. Writers are invited to see the act of writing as a ritualised, reflective endeavour that requires time, perseverance and commitment for emotional and physical health benefits to be achieved. They are encouraged to discover what setting and conditions are most conducive to working. Creating something on the page is seen as therapeutic and empowering in and of itself. Blocks and resistances are to be expected, but self-judgment and criticism are to be monitored, softened and hopefully suspended. It is assumed that some things are easier to write than to say aloud but that externalising difficult or emotionally charged stories is “healthier” than not telling them at all. Process is often valued over product—writers are told to closely observe bodily sensations and cognitive/affective experiences as they compose works, but not to worry about the literary quality of the result although they can revisit, edit or further craft the piece if they so wish. Writing exercises are generally provided and typically include techniques such as letter-writing, composing dialogue, “power-writing” (a form of time-limited automatic writing through free association), using lists and “clustered” thoughts and employing either open-ended or more directive health-related prompts. Authors are reminded that written stories live on as testimony and can be shared with others to good effect. Finally, a growing trend in these self-help books is to cite the ever-growing literature on therapeutic writing in order to support recommended strategies (see De Salvo 1999, table 2).54

How does writing help? Theoretic possibilities

Nature of the writing task

Accounts of how writing about trauma might confer psychological and physiological benefit show less agreement than accounts of writing’s beneficial health correlations.55 Some explanations have focused on the nature of the writing task involved. Across studies, structure in writing tasks ranges from open-ended, where the participant writes whatever comes to her mind, to programmed, where the participant completes homework assignments or lessons in an ordered workbook that focuses on specific clinical issues (ie, depression).56 Other variables across writing programmes include the time spent writing and the frequency of writing. The majority of studies follow Pennebaker’s early work30 in employing a medium level of structure through focused writing tasks that emphasise the expression of thoughts and feelings associated with negative life events. However, subsequent studies revealed similar positive health outcomes using more structured writing programmes,37 43 while others demonstrated the benefit of journaling, a highly individualistic, free associating expression that has meaning to the writer but may not be fully comprehensible to another reader.57 Still others have shown that subjects benefit from writing tasks that focus on positive rather than negative aspects of stressful experiences.58 The success of such a diverse range of writing tasks suggests that the specific structure of writing tasks cannot fully explain the source of writing’s benefit.

Emotional expression

Other theorists have construed expressive writing as an extension of the early psychotherapeutic abreaction theory, pointing to the act of expression as the therapeutic component rather than specific nature of the writing task. Abreaction theory, a precursor to the talk therapy pioneered by Breuer and Freud59, posits repression of negative experiences as the precipitant of poor psycho-physical health outcomes, and conscious expression as key to alleviating symptoms associated with traumatic events.1 60 It is possible the act of divulging a previously undisclosed traumatic event might account for therapeutic benefit across writing tasks.30 While some studies support this suggestion by showing an increased benefit among participants whose trauma was previously undisclosed61 most found no difference between writing about a previously disclosed versus undisclosed trauma.62 63 Perhaps the strongest evidence against this claim is Greenberg, Wortman and Stone’s64 study demonstrating no difference in positive health outcomes between subjects writing about a fictional trauma and subjects writing about an actual trauma. Further, in a recent meta-analysis of writing task studies, Pennebaker29 demonstrated that the use of insight words, causal words and words associated with cognitive activity was a better predictor of psycho-physical health benefits than overall emotional expressiveness. Another recent meta-analysis of 61 emotional disclosure studies found that emotional disclosure had no significant impact on physiological performance, immune response and psychological outcome relative to controls.50 In light of these studies, we might prefer an explanation that pinpoints unique aspects of writing and reflecting on stories with emotionally evocative content as the source of therapeutic writing’s benefit, whether or not these stories deal with autobiographical events and whether or not the writing task focuses on emotional expression.

Cognitive processing

One possibility is that therapeutic writing facilitates the integration of disjointed traumatic memories. The creation of narratives is an essential psychological activity involved in the ongoing processing of experiences.22 For example, narratives may be involved in directing attention, interpreting events and transforming experience into memory. In support of the role of coherent stories in cognitive processing of experience, early studies on story comprehension showed that adherence to expected patterns of textual structure facilitated the encoding, representation and retrieval of story information.65 Participants had difficulty comprehending, storing and recalling stories that did not follow expected patterns of cause and effect between events, agents and goals.66 67 This early work on “story grammars” supports a link between story coherence and encoding of experience, such that creation of shaped stories, composed with logical and goal-focused connections between story events, might aid the integration of their content.

Creation of coherent narratives is interrupted in the case of traumatic experiences. Memories of traumatic or stressful experiences are described as more emotionally vivid, uncondensed and disorganised than non-traumatic memories, often appearing as disconnected perceptions with no unifying linguistic form.22 68 69 70 As a result of their poor organisation, traumatic memories are highly accessible to working memory. In particular, they are recalled by a wider variety of triggers than memories that have been integrated into coherent schema.60 68 The intrusion of traumatic memories into working memory may result in an automatic process of suppression or distraction, which consumes working memory resources71 72 and heightens the accessibility of stressful memories through the negative feedback processes involved in repression.73 Therapeutic writing may help an individual to structure disorganised stressful experiences, reducing their recall and thereby making traumatic memories less likely to compete for limited working memory resources. In turn, decreased strain on working memory could improve problem solving and lead to psychological and physical health benefits.68 This view suggests that the ability to construct organised narratives is an important skill for successful coping with life stressors and trauma, enabling individuals to construct coherent stories from fractured memories and to facilitate cognitive processing of traumatic events.

Research supports a link between cognitive processing of traumatic or stressful events and therapeutic writing’s positive impact on health. Reflecting on the evolution of expressive writing as a therapeutic technique, Pennebaker has pointed out that clients who are adept at writing good stories and whose perspectives change during story writing tend to show the most pronounced health improvements.29 In a meta-analysis of therapeutic writing studies, he found that participant’s use of keywords suggesting insight, agency and autonomy was the strongest contributor to positive psycho-physical outcome following writing tasks, independent of emotional expression.29 74 75 76 Organising emotional experiences into a coherent story has also been associated with greater benefits than writing in a disorganised way.57 60 68 Pennebaker asks, “Can we ultimately train people to construct good stories that provide meaning and structure to their lives?”29 In other words, given the widespread evidence for story-writing’s positive impact on health, the focus now turns to whether narrative competence can explain and improve writing’s benefit.

Narrative competence

Development and attachment

The ability to identify narratives develops in children across cultures and does not appear to require explicit teaching.17 The universality and innateness of narrative abilities, however, does not preclude differences in narrative competence, and psychologists have noted that in early childhood narrative style differentiates correlative with parental attachment.77 For instance, one study by Newcombe and Reese78 examined the relation between parental attachment and narrative style longitudinally among a sample of children from 19 to 51 months of age. They found that narratives of children with a secure attachment style showed greater consistency, more well-developed evaluations, and incorporated more bidirectional links between events than narratives of children with an insecure attachment style. The link between attachment in infancy and narrative style in adulthood suggests that narrative competence may be partially acquired through parental attachment in early cognitive and social development; at the same time, the ability to represent and reflect on events in a complex way may facilitate the development of secure attachments with others, in childhood and adulthood.79

Theories of competence

What exactly does it mean to be narratively competent? Narrative abilities seem to be a universal feature of human cognition. The precise skills involved in creating and understanding narratives has been the subject of inquiry across disciplines, spanning pedagogical, literary, sociological, psychological, linguistic, cognitive and medical theories. Early work in the study of narrative competence borrowed primarily from advances in linguistics, emphasising an investigation of narrative grammar.10 80 However, as Prince points out, linguistics is concerned not only with syntax, but also with the meaning of sentences and stories.8 In addition to global and local generation rules for narrative structure, a complete study of the structure and function of narratives should provide semantic rules for interpreting global (the moral of a story) and local (sentence) information contents, transformational rules specifying narrative discourse, pragmatic rules concerning the suitability or tellability of a mode of discourse, and rules of expression that enable translation into different narrative forms. Narrative competence, in this view, would extend beyond the ability to create and detect connections between events to the interpretation of appropriate story meanings from ambiguous story structures, as well as the ability to communicate meanings to others using narratives. For instance, in his seminal work on the structure of poetics, Jonathan Culler81 defined narrative competence as a set of conventions necessary for narrative performance, such as narrative creation, interpretation, critical analysis and so forth. Educational policy makers have adopted a similar approach to defining narrative competence, enumerating the skills and competencies necessary for improving literacy, for example, “to identify, to understand, to interpret, to create and to communicate”.

At the beginning of this review, we defined “narrative” as a story that provides the form for interpreting experience, typified by an act of emplotment as opposed to description of events. Accordingly, we might think that another aspect of narrative competence is the ability to draw complex connections between events in the creation and interpretation of narratives, while maintaining coherence and fidelity to standards of credibility8 12 In literary theory, narrative competence also includes the critical ability to identify good narratives that are effective or masterful in expressing their intended meaning.

The study of narrative competence has thus moved away from the centrality of a reductionist account of narrative grammar towards a greater emphasis on the ability to construct interpretations and communicate meaning, and the role of context and culture.82 83 84 85 Broadly speaking, the multi-disciplinary exploration of narrative competence has focused on two areas: the ability to construct and comprehend goal-oriented connections among temporally situated events or emplotment; and the ability to understand and communicate contextual interpretations of ambiguous story structures or meaning. With this in mind, we can now turn to specific examples in medicine and clinical psychology to explore how this view of narrative competence translates into practice.

Therapeutic applications

Within narrative psychology, we can see this definition of narrative competence at work in therapies that emphasise a clients’ capacity to construct and interpret plots (for example, of their “life story”), as well as understand and communicate meaning to others. Clients may be asked to reflect on their story’s form to establish a coherent beginning, middle and end; to emphasise human impact, intimacy and a genuine sense of the author’s experiences through disclosure and voice; and to transform perspectives across the course of a written work.86 Fostering and exercising these story-writing skills engenders self-reflection and awareness, empathy for divergent perspectives, and new ways of perceiving life’s problems and meaning.87 At the same time, making one’s story comprehensible to another invites relationality and may also make it more clear and resonant for the writer. At the cognitive level, exercising these narrative abilities may facilitate the processing of stressful or traumatic experiences. By encouraging individuals to identify cause and effect between events and effectively communicate trauma-narratives, narrative competence facilitates narrative completeness and processing of stressful experiences.22 The promotion of narrative competence in therapy thus affects clients on multiple levels: from the cognitive level, to the level of intra-personal psychology, to inter-personal relationality.

The use of story-writing in healthcare is most prominent in the techniques of narrative medicine, which emphasise physician’s narrative competence as means to empathic understanding of the client’s experience.88 Medical programmes for narrative competence have so far been applied mostly to healthcare workers in order to facilitate medical practice that is empathic, respectful and sensitive to client’s illness-narratives, thereby humanising physician-patient relationships.5 89 90 The doctor-patient relationship may be enhanced by narrative skills like close reading, reflective writing and authentic discourse that facilitate transcendence of boundaries between patient and physician, physician and self, physician and colleagues, and physician and society.5 For example, medical residents may be asked to write their own “personal illness narratives” to reflect on their own experiences of illness, forgoing the pervasive medical dichotomy that emphasises patients’ bodies while distinguishing physicians by their minds.87 89 Physicians who have developed narrative competence may also help clients change problem-saturated stories by incorporating the patient’s narrative in treatment. For example, a physician might use the therapeutic relationship to help re-name and externalise problems, or employ medical rituals, documentation and the physician’s role as audience as reinforcements for therapeutic change.91

Supported by qualitative case studies and transcripts of physician-patient interaction, narrative competence is a promising frontier for effective medical practice. While traditional models of medicine privilege physician narratives that interpret the client’s story according to the therapists’ pre-existing theory of pathology, writing therapy demonstrates the positive impact of mutual story-creation on health outcomes.18 The success of narrative medicine in creating better patient care further suggests that narrative competence can be improved.88 92 93 Less attention has been paid to the potential for teaching narrative competence to patients suffering from chronic illness so as to incept parallel benefits, though such work is underway, as described below.

Group narrative-based therapy and chronic illness

While there are many ways for an individual to achieve narrative competence, group settings provide an ideal environment for developing narrative skills. The act of putting experiences into written form may inspire a coherent retelling of previously disjointed events; alternatively, presenting stories to a group may precipitate a shift in perspective through co-constructive interpretations; similarly, the insights of external observers may illuminate new connections or construal of disjointed events, or highlight points of in-authenticity, ambiguity or unexpected interpretations of stories. Through co-construction, narratives are taken up by a group and transformed, introducing new and possibly unexpected meaning to a story. In seeking to understand stories, group members are challenged to consider new perspectives, cultural identities and contexts in a supportive environment. Likewise, story-tellers learn to communicate effectively with a group, thus providing motivation for elucidating clear and affectively provocative narratives.18 Group therapy provides a unique environment for exploring and improving narrative competence because of its emphasis on relationality and its provision of a container for the reading or oral exposition of written stories. This in turn may help individuals construct complete life narratives incorporating past trauma or ongoing stressors, thereby facilitating their cognitive integration.

Narrative competence is especially important for reclaiming life narratives in the face of cultural stigmatisation and prejudice.93 Therapeutic writing groups may be particularly efficacious among individuals with chronic illness and members of stigmatised groups. Fostering narrative competence through a group setting allows members to celebrate their identity within a context of acceptance and expand their concept of self.18 Perhaps for this reason, group writing therapies have been helpful to individuals living with AIDS, for whom the confrontation of a life-threatening chronic disorder is compounded by social stigma.18 One clinical model, called Narrative Competence Psychotherapy (NCP), is essentially a hybrid of writing workshop and a “working group psychotherapy”. This model emphasises a shared task and product, and encourages HIV positive patients to write over 12–16 weeks about emotionally resonant incidents using suggested prompts, to form these stories with a beginning, middle and end, and to read them aloud in a group.94 In adopting a narrative model of therapy, clients are encouraged to create a new context to counteract the negative construal of AIDS often encountered in the dominant culture. This helps maintain integrity and identity as individuals confront the limitations and harsh realities of living with severe chronic illness. The efficacy of Narrative Competence Psychotherapy for individuals living with AIDS is attested by numerous psychological benefits including newfound clarity surrounding life experiences, new perspective and insight into problems, and satisfaction at having created and shared something concrete that will live on as a testimonial.95 96

In addition to qualitative case studies showing the psychological benefits of narrative competence therapy for individuals living with HIV, expressive writing has been associated with a drop in HIV viral load and increased CD4+ lymphocyte count among a sample of people with HIV.76 Frequency of insight/causation and social words in narratives of people living with HIV is also correlated with better immune-functioning and positive health changes,74 supporting the view that emotional expression and cognitive restructuring contribute jointly to positive health outcomes.97 In light of previous research on expressive writing and the role of fostering narrative competence in healthcare and chronic illness, group Narrative Competence Psychotherapy and models similar to it represent a promising horizon for helping people to cope with ongoing stressors, improving physical and psychological health following the trauma of illness, and constructing adaptive life narratives even in the face of cultural resistance. The following vignette demonstrates how a patient made use of therapeutic writing in a group over time.

Case study from the NCP groupi:

James is a 48-year-old divorced father of a grown son who moved alone to Toronto from western Canada to seek work in the 1980s. He let the writing group know that he was a recovered alcoholic but divulged little else about his life, sexuality or current relationships. He was often ill-kempt with unwashed long grey hair and rumpled clothing. His voice and hands trembled markedly each time he read a piece to the group, but nonetheless, he “forced himself” to take a turn reading. He would then apologise profusely for “the poor quality of his stories” and his “inadequate delivery”. Group members gently and repeatedly advised him “not to be so hard on yourself” and to “ditch the inner critic”. James participated in three 12 week sessions of group therapeutic writing and his confidence to participate increased as the group supported his taking risks and sharing more. His early narratives were indeed fragmented, chaotic and incomplete and he “couldn’t say why he wrote what he wrote”. Over time, the narratives he selected to share became more organised and self-revealing as they progressed. At the end of his last group, James shared a surprising insight

I’ve been using all your darned prompts—write about a gift, write about a good-bye, write about a place—and when I was putting all my stories together in a binder, I realised something that I guess you would call unconscious. They were all about John [the male partner he had lost to AIDS but had never mentioned by name in the group]. Every single one—the lighter he gave me; where we met; the day he died. I didn’t even realise I was doing that.

Putting it all together: learning from the literature and from the Mount Sinai therapeutic writing (NCP) model

John McLeod98 has written about narrative work being different from psychotherapy in several ways. First writing is a universal skill in literate populations and is by definition, a non-medical act which can be self-initiated at no cost. Stories told in more medical contexts are abbreviated towards the purpose of diagnosis, which in itself can be seen as an anti-narrative set. The medical story is distilled in anticipation of a treatment plan, rather than being “opened wide”. Even stories fleshed out in psychotherapy tend to emphasise problems, conflicts or points of being “stuck” whereas written narratives not prompted by a “problem agenda” can celebrate pleasure, beauty or an emerging sense of mastery. Likewise, stories told with others in mind tend to be clearer than journal entries, which is the form of writing often used in therapeutic contexts. They are more formed, crafted and allow for playful experimentation with voice, character development and metaphor. The storyteller/writer can also re-discover multiple selves. For many in the Narrative Competence Psychotherapy group, the pre-AIDS self could be honoured alongside the self as patient, now living with a chronic illness and imagining a future. Any story can have multiple interpretations and can counter prevailing sexual or cultural consensus narratives about what life with HIV/AIDS might mean. Group members were often surprised by the interpretations members gave around their read story, suggesting that there is “always a story underneath a story”, and that most accounts have more than one possible meaning. As well, due to the supportive nature of the group, members could revisit a piece, edit it and retell it, all the while flagging emotional blocks, clichés or missing yet vital pieces of information. Receiving feedback on whether the story “worked” or not as a piece of writing also challenged the teller to confront what really happened, and express this reality, so that the story could be more fully comprehensible. It can be argued that many of these narratively derived elements are of course incorporated into the co-constructed shared telling of stories in all forms of individual psychotherapy. But the NCP model offers the possibility of more “fleshing” out than the thought record of cognitive-behavioural therapy, and obliges more shape and precision than the free-associated, often fragmented, ongoing storytelling of insight-oriented psychotherapy or psychoanalysis. Committing the story to the page also provides a sense of mastery and satisfaction. There is a creative product that allows externalisation of thoughts. As one member put it, “Some things are easier to write and read on the page than to say”. Writing also encourages meta-cognition or an observing ego. The authorial narrator may offer more insight than the author could have, without having crafted the incident into a meaningful account. Finally, and particularly pertinent to individuals with a life-threatening disease, written stories live on as a testimony, elegy or historical record, and can be shared with friends, families and communities. Stories live on.

Participants’ feedback

It seems fitting to conclude this theoretical analysis on therapeutic writing with specific comments and observations from patients in the Mount Sinai NCP group. At the end of each 16 week session, participants were provided with anonymous feedback questionnaires and asked to write comments about their experience with the group. Most members viewed their NCP group experience positively and felt they benefited from it, as suggested by the following comments, grouped here under specific themes. Their remarks appear to confirm many of the theoretical conclusions noted above in the literature review. These anecdotal remarks also suggest that patient narratives evolve over time through retelling to self and others. This change in patient narratives opens the possibility that stories themselves may be used as outcome measures.

1. Some participants’ comments provided comparisons with previous psychotherapy experiences:

    • “Not problem-based only”

    • “Non-medical”

    • “Helps me to cope with depression without focusing on depression itself”

    • “Had to make something rational, organised—have to confront things without rambling”

    • “Writing celebrated my past versus forgetting what I said in therapy the week before”

    • “Had to think it through rather than tell it off the cuff like in therapy”

    • “Less likely to forget my stories versus forgetting what I said in therapy the week before”

    • “With a therapist you develop a short-hand. With stories they have to be comprehensible every time”

    • “More varied perspective than in individual therapy”

    • “Emphasis on working on something”

    • “Easier to write than say certain things”

2. Some members identified a change in perspective or outlook after writing and sharing personal narratives:

    • “Possibility to re-read then re-analyse my old thoughts”

    • “Got my head out of my ass”

    • “Took a look at procrastination and my inner critic”

    • “Learned to give constructive criticism—can use it on myself”

    • “Finally finding your own voice”

    • “Increased tolerance for taking risks to tell and present a story”

    • “More varied perspective—not just a gay man with HIV”

    • “Stories broaden your horizon”

    • “Allowed me to bring stories to my own therapy for discussion”

    • “I can mine my life with HIV for stories”

    • “Storytelling a very intimate way of interacting with others”

    • “Helps me communicate better in general”

3. Participants spoke of satisfaction in the craft of writing and in producing a tangible product.

    • “Able to revise and polish so it can be heard”

    • “Group asked right questions—editing helped me work through emotions”

    • “Never realised the beauty of language—its rhythm and cadence”

    • “There’s an art to listening”

    • “Creative—something results and there is a record of it”

    • “I want to get publish(ed)—new goal to become a writer”

    • “New crisis tool I can use on my own”

    • “Now able to share my stories with my family so they can understand me better”

A meaningful footnote:

In 2007, participants from 16 previous therapeutic writing groups were asked to submit stories they had written in the Mount Sinai programme for potential inclusion in a published anthology. Still here: a post-cocktail AIDS anthology was released last year to the satisfaction of “group graduates” and to positive review from the HIV/AIDS community.99

For more information on this book, as well as a detailed technical description of the Narrative Competence Psychotherapy model (including writing prompts) go to http://www.ohtn.on.ca/Pages/Publications/StillHereReview.aspx (accessed 29 Sep 2009) and can be purchased at http://www.liferattle.ca (accessed 29 Sep 2009).

Excerpt from Still here:

The following narrative by David King (a pseudonym) embodies six key elements of autobiographical/narrative competence as defined in the literature (see box 1).

Box 1 Elements of narrative competence

  • Coherent form (beginning/middle/end)  =  emplotment.

  • Self-revelation and reflection.

  • Emotional honesty.

  • Thoughtful/purposeful use of language (ie, metaphor).

  • Comprehensibility to reader, offers meaning.

  • Generates a response in the reader/listener.

Changes

Within hours, maybe even minutes, of learning I was positive, change was already incubating within me. Like most of the changes in my life, this one has proved to be worrisome and troublesome. Yet apparently it is well intentioned, seeking to better position me in withstanding the attacks of my viral invader. This change seems to have a life of its own and I must constantly cultivate it, prune it and feed it to get it to grow in the manner I want it to. It is also the largest and thorniest I have ever had to deal with since it impinges on so much of my life in so many ways—work, relationships, health, addiction, depression, sex.

Trying to cope with change in so many areas at once has proved to be overwhelming. For the past two years, it seems I have been running from one area to another trying to provide just enough attention to each before I have to move on. It’s a game of catch-up which I cannot seem to win. It reminds me of the summer I took care of, or tried to, Mrs McMaster-Worthington’s one acre garden. My hands were raw with blisters as I ran from flower bed to carrot patch under the hot sun, weeding, watering, fertilising, hoeing, digging. Sometimes dealing with the change that HIV has thrust upon me seems a hopeless task.

But two important things have emerged from this period of change—a sense of being able to cope with HIV without the fear and panic which first gripped me, and a sense of learning what change means and how to deal with it. Change, much like HIV, follows a slow progression along an uneven path. As I see and feel the changes that HIV is making in my body as it progresses, I also see and feel the progress of positive change within me. The HIV companion that haunts the dark places of my body, feeding on both my flesh and soul, has strangely gradually changed, taking on less the role of feared marauder to become more a part of me. This parasitism has evolved to mimic a symbiosis of sorts, where the battle between invader and host has become more balanced, where the constant warring between host and parasite has produced a climate in which, albeit only temporarily, neither wins nor loses.

There are wild orchids which grow near the dry, rocky cliffs of a rugged canyon near the town of Dorion. The roots of these orchids become invaded by a fungus, but in some way, the orchid usually responds to control the spread of this “infection” and the two live together in a state of constant battle in which neither triumphs over the other. The orchid is the source of food the fungus needs, providing it with sugars made by photosynthesis. The fungus collects scant water from the rocky soil to sustain the orchid and even produces vitamins which the orchid uses. In a similar way, I feed my HIV as it gives me in return a more sharply honed clarity of the meaning of life. It has taught me that I have to cultivate the changes that have been sown in a manner as relentless and unceasing as that of HIV itself as it shares my body. Somewhat like the uneasy relationship between the orchid and the fungus, HIV and I have developed an uncertain relationship in which I provide life to the virus while it provides a well-spring of change to me.

I don’t know what happens in time to the orchid, but I assume as it gets older and weakens, perhaps in its own way wearing of the constant battle, the fungus ultimately breaks through its defences and overwhelms the orchid. And so, in time, shall HIV with me.

– David King

REFERENCES

View Abstract

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • See Editorial, p 67

  • i This is a composite patient vignette. Specific details have been changed to protect the confidentiality of individual patients.

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