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

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

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

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

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

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

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

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

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

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

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

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

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

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