The Power of the Pen in Therapy

Q: I keep hearing that journaling has many benefits for clients. I like the idea, but I’m not sure where to start. How can I integrate journaling into my practice?

A: Perhaps the most important rule about journaling with clients is that there are no rules. Therapeutic journaling is a fluid, free-form kind of writing, with no need to worry about grammar, spelling, or punctuation. In its broadest sense, it’s any type of writing or expressive process used for the purpose of healing or psychological growth. By taking time in your sessions to have clients record their free-flowing thoughts and concerns, even for just a minute, they can explore issues they may be dealing with but find hard to verbalize, clear their minds, and have a list of things they’d like to cover with you during therapy. Journaling is also useful for clients to do between sessions to keep them connected to their therapeutic work and aware of changing thoughts and feelings.

Below are some suggestions for best practice. Because every client is different, it’s important for you to tailor your approach to each individual’s personal issues and comfort level.

Keep it simple. You don’t have to start with complex journaling exercises. Instead, you can suggest to your clients that they notice and write down their feelings for four days out of the week. If you want to get a bit more specific, you can invite them to attend to what they experience during the week by using the mnemonic device ATTENDD to guide their journaling process.

Awareness. Be aware of what’s going on for you between sessions by jotting down anything that seems to have changed or seems different in your life.
Tension/physical sensations. Pay attention to your body and note when you experience any tension or tightness.

Thoughts. Take note of any unusual or upsetting thoughts that come up and write them down. Once you write these thoughts down, does your thinking change?

Emotions. Pay attention to your emotions. Do you feel joyous, depressed, elated, or fearful? Are these feelings different from what you experienced in your last session?

Intuition. Stay conscious of anything that comes to you intuitively during the week. Do you instinctively have a better understanding or greater sense of knowing something about your relationships, your therapy, anything that’s been on your mind?

Dreams. As soon as you wake up in the morning, write down everything you remember about your dreams, including partial images, people, objects, and feelings.

Distractions. Pay attention to what, if anything, is distracting you. Is there a pattern you can discern within the distractions?

By using the ATTENDD approach and bringing journaling notes to future sessions, clients have a specific way to notice subtle changes and keep track of their progress.

Free-form writing. Free-form writing (alternatively called stream-of-consciousness writing) is simple, but not necessarily easy. Here are some ways to begin free-form writing that you can teach right in your office.

Ask your clients to close their eyes and pay attention to their breathing. Suggest that they notice any tension in their body and, if so, to let it go with the next exhale. Repeat this process for a few minutes, and then ask if they’re ready to begin. If so, set a timer for 10 minutes, or if that seems too long, try 7 or even 5 minutes. Have them write about whatever they notice, whatever they’re feeling or thinking, even if they’re thinking about not knowing what to write. The only thing they need to do is to keep writing, to keep their hand moving across the page—even if they feel they have nothing to say and come up with something like “I don’t get what I’m supposed to be doing. What’s the point of this? What if I don’t know what to write? What am I feeling? I’m feeling tired, tired down to my bones, but it’s not just physically tired. It’s like my whole being is tired, like my soul is exhausted and achy.”

For the decades that I’ve used this exercise, both personally and with clients, it never ceases to surprise me how quickly it can shift consciousness in just a few sentences. If this seems unlikely to you, try it for yourself.

Sentence completion. Maybe it’s a throwback to elementary-school workbooks, but I’ve found that for some clients, completing a sentence can be less intimidating than writing a complete one. If you create partial sentences for your clients, focusing content so it supports your treatment plan (perhaps inviting information that would be helpful for you to have but may be too threatening to ask about directly), you can suggest that they jot down the first thing that comes to mind when they read the sentence stem. If you have clients who struggle with depression or anxiety, you could have them complete the sentence stem “The last time I was depressed, I . . .” or “I get anxious every time I . . . .” Other sentence stems could be “When I drink, it’s not uncommon for me to . . .” or “What first attracted me to my partner was . . . .” Whatever your clients’ responses may be, they can be used for discussion throughout the therapy process.

Quick lists. Much like the sentence-completion exercise, writing a list quickly can tap into important preconscious or unconscious material. When I suggested that my client Elaine write a quick list answering the question “What stresses you out at work?” she scribbled down that she felt constantly interrupted, that she was underpaid, that she thought her commute was too long, and that her boss gave her the creeps. While she’d been aware of the first three responses, her last response hadn’t been processed at all, and it led to a deeper investigation of this feeling in our next sessions.

Another use of quick lists is to help clients focus on goals. Jon, a second-year law student, came to see me after finding that he wasn’t happy. He felt bad because his father’s dream had long been to make Jon a partner in the family law firm. But law wasn’t turning out to be Jon’s passion. I asked him, “If you could do anything you wanted to do in the world, what would it be? What are you happiest doing?” I suggested Jon write down the answers in a quick list, just jotting things down as quickly as he thought of them. At the end of this exercise, Jon put his pen down. He’d written three notes: “compose music, practice music, and perform music.” He was a brilliant musician, but had grown up hearing that music was not as a profession. He’d always known what he wanted to do, but on seeing his short, unedited list in front of him, he was finally ready to make some changes.

Three Good Things Plus. Although gratitude lists may seem like a pop-psychology phenomenon, evidence-based studies show that some symptoms of depression can be relieved through pointed expressions of gratitude. Martin Seligman and his colleagues suggest an exercise in which a client identifies three positive things that happened during the day. I’ve found this especially helpful if the lists are kept in a notebook, personal journal, or computer file. Having lists available in one place makes them easier to find and reread at a later time. I’ve found rereading lists has a positive cumulative effect. Rereading several positive phrases at one time can provide a boost of positive emotion.

My client Lillian suffered from periodic bouts of depression and low self-esteem. As she was getting ready to leave on a month-long trip, I asked her to take time each evening while she was away to write down three good things that had happened to her during the day. I also added a bonus exercise borrowed from positive psychology. In addition to the three good things she was to write down each day, I asked her to write down her part in making each good thing possible. She responded, “But I’m not responsible for the weather!”

“That’s true,” I said, “but you are responsible for deciding to go outside in it.”

Several weeks later, when Lillian returned to my office, I was surprised and delighted by the change in her. Despite her initial resistance to my suggestions, she’d followed through with her daily list of three good things and had taken on the bonus task of acknowledging her part in making each positive thing occur. Here’s an example of what she’d written: “Day one: Today I missed the train on the first leg of my journey. I couldn’t believe it, but it turned out that I met a man who told me about several great little cafés I hadn’t heard of that were close to places where I planned to stop. What was my part in this interaction? Although I was initially upset about missing my train, I was able to shift my attitude. I had a great day!”

What had shifted for Lillian was not just her change in attitude, but that she was now thinking of each positive experience from a perspective of personal causality. Not only was she more focused on the positive, but she was beginning to understand her role in creating good things in her life each day.

Don’t let the appearance of simplicity deter you from integrating therapeutic journaling into your treatment plans. It can have a surprisingly profound impact on your clients. But it’s not only your clients who may benefit: take some time for yourself to use journaling to help solve your problems, clarify your thoughts, and connect to your feelings. Find a quiet spot and pick up a pen!

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