Journaling

Although thousands of people journal, little has been published on its applicability to the healthcare setting as a means of documenting medical information and paralleling that information with personal observations, reactions, and impressions.  

In preparation for writing this ToolBox numerous people were asked why they journal.  Responses varied in actual words but several themes emerged. 

            "It helps me focus."
            "It allows me to order my day."
            "It helps me cope with stress."
            "It tells me where I've been, where I am, and where I am going."
            "It's my best friend because it's always there when I need it."
            "Whatever I write is OK. There's no judgmentalism."
            "It helps me put all of my important information in one spot where I know I will find it."

Other benefits include reconciling emotional conflicts, fostering self-awareness, managing behavior, solving problems, reducing anxiety, aiding reality orientation, and increasing self-esteem. The healing benefits of writing alleviate the constraints or inhibitions associated with not talking about an event. Specifically, written emotion promotes integration and understanding of the event while reducing negative emotions associated with it (2)

Whatever one's reasons for writing, journaling may be a relevant tool for the healthcare provider to offer to their patients.  This toolbox is provided as a means of assisting the healthcare provider in offering this opportunity to their patients. 

Numerous complementary techniques exist for patients to explore in adjusting to the reality of their altered health. This Toolbox describes one of them:  writing, journaling, logging information, keeping a diary. Whatever it is called, it offers an opportunity for helping patients focus, order their day, indicate where they have been and where they are going, put their lives in perspective, and keep relevant information in one location.

The literature describes three types of journaling:  therapeutic, creative, and reportive.  Although this toolbox is focuses primarily on reportive and creative journaling, an understanding of the therapeutic journaling is relevant.

Therapeutic Journaling:

Most patients experience some grief in the course of dealing with their cancer.  "Because grief is not pathologic, its facilitation originates from a wellness conceptual framework." (3).  Therapeutic journaling has received significant acclaim by studies conducted by Pennebaker, (4,5) one of several psychologists who developed a standard writing task.  He asked his subjects to write an essay that expressed their feelings about a traumatic experience in their lives and showed that such an experience  improves immune function.

Using the model of Pennebaker, the Journal of the American Medical Association published a trial of a "get it off your chest" writing exercise.  Seventy one patients with asthma or rheumatoid arthritis were randomized to write about the most stressful experience they had ever had for twenty minutes over a few days, as compared with a control group.  Findings from this study showed a significant improvement in standard measures of disease severity four months later. "Although it may be difficult to believe that a brief writing exercise can meaningfully affect health, this study replicates in a chronically ill sample what a burgeoning literature indicates in healthy individuals." (6) 

It remains unknown whether these health improvements persisted beyond the four months.  It is also not known whether or not these findings can be generalized to other acute or chronic conditions. (7)

David Spiegel responded to this study with an exhortation to "abandon the Cartesian split between mind and body, and acknowledge the growing evidence in support of behavioral interventions that reduce emotional stress as therapies for diseases that are mediated in part by the immune system. (8)  Spiegel reported evidence that patients with breast cancer who express negative emotions (9) or the "fighting spirit" (10) actually live longer than those who don't. Speigel summarizes this information  by stating that if comparable research were found on a new drug, it would be in wide-spread use; however, "manufacturers of paper and pencils are not likely to push journaling as a treatment addition" (11).

When patients begin to journal their memories, their writings are often disorganized (12).  DiSavino (13) found that evidence of decreasing disorganization over time was associated with improvement.  Similarly, Pennebaker (14) found that a narrative becoming more focused and coherent over writing sessions was associated with increased improvement.

In the therapeutic setting, the therapist often provides the patient with a set of instructions regarding the length and focus of the writing session. Often patients are asked to write without censorship or concern for style or grammar.  Although journal therapy is often provided by certified instructors who receive variable amounts of training, journal therapy is best administered by a licensed psychologist or psychiatrist. While journaling classes are available to the public, therapeutic journaling is ideally conducted in a supervised setting where issues can be appropriately addressed.

David Spiegel summarizes the relevance of complementary therapeutic techniques such as writing by stating, It is not simply mind over matter, but it is clear that mind matters." (15)

Creative Journaling:

Writing is an active statement of externalizing an internal experience and becomes a prelude to proactive problem solving by patients Writing one's reactions to medical conditions that are happening a daily basis can afford the patient an opportunity of understanding these situations on a deeper and more personal level.  Often patients are reticent to describe these feelings to others either because they lack the words to convey the depth of their observations, or because they are embarrassed to speak openly (16).  Written dialogue provides an opportunity to tap a deeper wisdom that typically is not accessed through the spoken word or through  more logical, linear methods (17).

Similar to keeping a diary, creative journaling may be as expansive as the individual desires. It may include a specific note written every day or be written sporadically.    It can take whatever form the person wishes, be maintained at the level they desire, and be composed on paper, a word processor, a tape recorder, or even a videotape. You may want to include drawings, doodles, and scribbles. It may be written in prose or poetryor just randomized thoughts. You may write long dramatic dialogues or letters, include graphs and charts, and utilize colors, abstract designs, images, and symbols.

Creative journaling is a tool for personal growth, life planning, spiritual introspection.  Whatever is written, it must be kept confidential. If the writer feels that it will be shared with others, the flow of information will be altered. Worrying about what someone things or will say about one's journal entries defeats the whole purpose of journaling.

Reportive Journaling:

The uses of a health diary has been common in nursing practices, as a means of helping patients document their symptoms and the factors that precipitate them, such as pain (18) and fatigue (19).   To date there has been limited exploration of this tool in a nursing research context, yet the diary has been used as a tool since the 1950s. (20) The term diary is used to refer to an annotated chronological record or log. For purposes of this tool box, it will be considered synonymous with Reportive journaling. 

Diaries have been used to collect information about an individual's health and illness behaviors.  Patients usually keep the data themselves; however, family members may assist. Rakowski found that monitoring on a daily basis permitted more accurate information than relying on recall techniques which often under-report short-term discomforts, nagging low-grade chronic conditions, and minor health problems.  Individuals may retrospectively define past episodes as having been more or less serious, based on the current long-term effects rather than what occurred at the actual moment. (21)

In a series of Medical Research Council which involved chemotherapy and radiotherapy for lung cancer patients, daily diary information was found to be sensitive in detecting day-to-day changes in symptoms (22, 23)

Richardson identified the following advantages of utilizing reportive journaling:

• Produce rich data regarding processes used to promote health and cope with illnesses in individuals over time
• Support dynamic as well as static analysis
• Does not rely on retrospective reflection, thus reduces recall error
• Can be descriptive and intimate
• High levels of reporting achieved when compared to retrospective interviews
• A series of events can be documented and examined for causal relationships.

And the following disadvantages:

• Time required to instruct about the tool and follow-up
• Bias in that excludes participants who cannot read or write
• Inability of the interviewers to probe for further information, must be taken at face value
• Dependent on the motivation of the participant
• Crucial information may be omitted or skipped
• Conditioning effects may occur
• Survey costs are high
• Data collection, processing, and analysis may be complex, if you chose to use this information in research studies (24).

It is ideal if patients can record relevant information in five to ten minutes per day. They should be personalized to the individual and the patient should be encouraged to "make it their own."

It is important that creative journals be kept confidential. Likewise, it is important that confidentiality  remain in the creative writing section of this toolbox.  It is the design of this journal that it be shared with others.  Boundaries just need to be respected.

References:

• Oprah quote, http://www.nowgetcreative.com/journalilng.htm
• Slomski G. Journal Therapy. The Gale Encyclopedia of Alternative Medicine, Krapp, K, Longe JL, Editors.  Farmington Hills, Mich.: Gale Group, 2000.
• Rancor, P, Brauer K. Use of letter writing as a means of integrating an altered body image: A case study. ONF 2003; 30(5): 841-846.
• Pennebaker JW, Colder M, Sharp LK. Accelerating the coping process.  J Per Soc Psychol 1990; 58:528-37.
• Pennebaker, JW, Kiecolt-Glaser J, Glaser R. Disclosure of traumas and immune function: health implications for psychotherapy. J Consult Clinc Psychol. 1988; 56:239-245.
• Smyth JM,Stone AA, Hurewitz A, Kaell A. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: a randomized trial. JAMA 1999; 281:1304-9.
• Ibid.
• Spiegel, D. Healing words: emotional expression and disease outcome JAMA 1999;281:1328-9.
• Posener JA, Schildkraut JJ, Samson JA, Schatzberg AF. Diurnal variation of plasma cortisol and homovanillic acid in healthy subjects. Psychoneuroendocrinology 1996; 21: 33-38.
• Yehuda R, Southwick SM, Krystal JH, Bremner D, Charney DS, Mason JW. Enhanced suppression of cortisol following dexamethasone administration in post traumatic stress disorder. Am J Psychiatry. 1993; 150:83-86.
• Spiegel, ibid.
• Foa, E, Riggs D. Post-traumatic stress disorder in rape victims. In J. Oldham, M.B. Riba, & A. Tasman (Eds.), American Psychiatric Press review of psychiatry; 12: 273-303. Washington, DC: American Psychiatric Press.
• DiSavino, P, Turk E, Massie E, Riggs D, Penkower D, Molnar C, Foa E. The content of traumatic memories: evaluating treatment efficacy by analysis of verbatim descriptions of the rape scene. Paper presented at the 27th Annual Meeting of the Association for the Advancement of Behavior Therapy, Atlanta, GA, November 1993.
• Pennebaker JW. Putting Stress into words: health linguistic, and therapeutic implications. Behavioral Research Therapy. 1993; 31:539-548
• Spiegel, ibid.
• McGihon, NN. Writing as a therapeutic modality. Journal of Pscho-social Nursing and Mental Health Services. 1996; 34(6):31-35.
• Day, AL. The journal as a guide for the healing journey. Nursing Clinics of North America.  2001; 36:131-142.
• McCaffery M, Beebe A. Pain: Clinical Manual for Nursing Practice. 1989. CV Mosby, St. Louis.
• Piper B. Fatigue. In Pathophysiological Phenomena in Nursing: Human Responses to Illness (Carrieri V, Lindsey A, West C eds.), W.B. Sanders, Philadelphia; 219-234.
• Richardson A. The health diary: an examination of its use as a data collection method. Journal of Advanced Nursing. 1994; 19: 782-791.
• Rakowski W, Julius M, Hickey T, Verbrugge L, Halter J. Daily symptoms and behavioral responses: results of a health diary with older adults. Medical Care. 1988;26(3): 278-297.
• Jones D, Fayers P, Simons J. Measuring and analyzing quality of life in cancer clinical trials: a review. In The Quality of Life of Cancer Patients (Aaronson N & Beckman J. eds.), Raven Press, New York; 1987: 41-61.
• Bleehen N, Fayers P, Girling D, Stephens R. Report to the Medical Research Council by it Lung Cancer Working Party prepared on behalf of its participant members. Survival, adverse reactions and quality of life during combination chemotherapy compared with selective palliative treatment for small-cell lung cancer. Respirator Medicine; 1989 83(1): 51-58.
• Richardson, 784.