Evidenced-Based Outcomes for Self-Expression

2014 ATRA Mid-Year Conference

Danny Pettry

Introduction

Icebreaker Speaker Bio

Outline of Session Goals and Objectives

Icebreaker Activity

This may be shortened if there are a lot of people in this training session.

• Who are you? Where are you from?

• What do you do?

• Do you keep a journal? Any volunteers to share their personal entries? Just kidding.

Speaker Bio

• Discovered RT in 1999• ATRA Member since 2000• Undergraduate degree, Marshall University, 2002• Hired as a Rec. Therapist, 2002• Certified Therapeutic Recreation Specialist, 2003• M.S. Rec. Therapy, Indiana University, 2006• DannyPettry.Com (RT Web-site and blog), 2007• M.Ed. Counseling, Lindsey Wilson College, 2012• National Certified Counselor, 2013 • Provisionally Licensed Counselor, 2013

Session Description

• Improve the participant’s master of implementing a journaling/ self-expression program (as an RT/TR intervention) when appropriate for an individualized treatment plan based on assessment. The focus will be on the stress management and overall health outcomes through the use of self-expression with an emphasis in journaling.

Learning Objectives

• A. Identify at least 3 therapeutic and healing benefits for journaling and expressing emotions

• B. Identify at least 2 adaptive techniques for journaling

• C. Identify at least 2 concepts for motivating participants to being journaling when it would be in their best interest.

Part I

Assessment Process

Assessments

• A person should receive a holistic assessment that addresses these domains: social, physical, cognitive, affect/ emotional.

Strength-Based

• We are strength-based practitioners. We looks for what is working well with individuals and help them to build on their strong points in the domains.

• Example: worker said, “All I’m hearing is bad stuff about the kid.” As a RT, I was able to tell her what he was doing well.

• We also address areas of needed improvement in those domains, too.

Balanced Wheel

• It is an informal self-report assessment.

• Color/ shade in each section to demonstrate how happy/ satisfied you are with that domain area.

• Use a 0 to 10 scale for each section.

• Activity can be found with internet search. Many are in the public domain for use.

Balanced Circle AssessmentSocial Physical

Affect/ Emotion

Cognitive

Spiritual

Leisure

Work or school Recreation/ Leisure

Questions

• Example: Drawn on board.

• What would happen in life if your wheel was rolling down the road?

• Could you go at the speed limit?

• Would you need to go slower?

• Would you be prepared for a ditch or a hill if needed?

Review of Records

• You can read the records to gain information as well. Based on my experiences, this has been helpful when working with children and adolescents who may minimize their aggressive behaviors or play forgetful.

Standardized Assessments

• Beck Depression Inventory

• Beck Anxiety Inventory

• Beck Hopelessness Scale

These are copyrighted assessments.

They are self-report questionnaires.

Summary of the Assessment

• A well-written summary of the assessment is needed.

• Include methods used: review of records, any standardized assessments, interview with patient, observation of patient in activity, or other methods.

• Identify patient strong points in domains. Identify patient needs in domains.

Part II

Program/ Intervention Planning

Interventions

• RT is to assist the patient with maintaining and promoting strong points. (holistic model). Aims to work on what is working well. Prevention technique.

• RT is also to assist the patient with addressing functional needs. (medial model). Looks for what is wrong and not working. Intervention technique.

Interventions

• Interventions must target areas.

• Goals must be in alignment with overall treatment/ care plan.

• Better written goals make outcomes easier to measure.

• It doesn’t take any more time to write a good/ measurable goal than it does to write a bad/ immeasurable one.

Book Recommendation

• Reference Manual for Writing Rehabilitation Therapy Treatment PlansBy Penny Hogberg, Mary Johnson – This book gives examples of target need, goal

for the patient, measurable objectives for the patient to achieve, and interventions for the RT/ practitioner to use to assist patient in meeting her goals.

Part III

Evidenced-Based Outcomes for

Self-Expression

(with emphasis on journaling)

What is journaling?

• Journaling: the act of writing about one’s thoughts and feelings.

• Journal according to Webster’s dictionary is: record (as in diary) of daily happenings.

• Diary according to Webster’s dictionary is a record especially for personal experiences and thoughts. A book.

• We call them “thought logs”

Is journaling a leisure activity?

• Leisure is living in relative freedom from external forces in order to act from internal ways that are pleasing, worthwhile, and provide a basis for faith (Goodale & Godby, 1985).

• According to this definition, could journaling be a leisure activity?

• It could be leisure if the person is not being externally forced to write and it enjoyed.

Aristotle viewed “writing” as leisure

• Aristotle, one of the first philosophers regarding the concept of leisure argued that there are two types of education:

• Instruction on how to use leisure honorably:

• Reading/ writing, gymnastics, music and art.

• Instruction to develop occupational skills:• Math/ money making, household management,

politics and sciences.

Writing as a Creative Art

• Pressfield (2002) in his book The War of Art argues that writing is a form of creative art. Pressfield’s book discusses how to use leisure time productively to perfect one’s craft at writing.

• Pressfield had used the same creative techniques to write the novel: The Legend of Bagger Vance.

Journaling and gender

• Some people argue that journaling is an activity for women.

• This has been very true based on my personal experiences having provided services for adolescent males in the past.

• Fact that I use: Former U.S. President Ronald Reagan kept one of the most detailed dairies among all Presidents in history. Jimmy Carter also wrote journals.

Journaling and Longevity

• Dr. Maoshing Ni (2006), in his book: Secrets of Longevity: Hundreds of Ways to Live to be 100 argued that:

• Mental stimulating activities (learning and writing) can stimulate brain cells and in some cases grow new brain pathways

• Suggests that it is good for health to express one’s mind opposed to holding feelings inside.

Dr. Maoshing Ni on Longevity

• Ni (2006) compares a “mental dump” with a bowel movement. Ni argues that a person should solve this “mental constipation” with the use of journaling, which could add years to the lifespan.

• Interesting fact: Reagan, had written diaries, short fiction, sport stories, numerous letters, and poetry. He was the eldest President, serving from 69 to 77.

Bibliotherapy

• Bibliotherapy (wikipedia, 2007) is an expressive therapy that uses an individual’s relationship to the book, poetry, or other written words as therapy.

• Bibliotherapy is most often combined with writing therapy.

Bibliotherapy

• The use of Bibliotherapy is also discussed in Dr. David Austin’s (2013) Therapeutic Recreation Process and Techniques. 7th edition. Sagamore Publishing.

• It could be beneficial to have your patient read famous journals by people who have suffered similar incidents and to keep a journal about their own personal issues: physical rehab, substance abuse, etc.

Use of journaling in schools

• Teacher Erin Gruwell a.k.a. Mrs. G. taught at Woodrow Wilson High School, Long Beach, California

• Being the new teacher, she was given the worst of the worst.

• Children in her class were involved in gangs, drugs, racial wars, and had experienced loss from shootings.

Erin Gruewell’s Strategy

• Erin Gruewell realized that her students needed more than just English.

• She used bibliotherapy and writing therapy in the classroom to help her students to build esteem, confidence, acceptance of others, how to cope with issues in life, and so much more beyond the basic education curriculum of high school.

• She went the extra mile and was criticized by other teachers because teachers felt she was making them “look bad.”

Newspapers argue the benefits:

• Cathartic writing course records students pain. • Writing to heal: teenagers explore their problems

through writing. • Literature transforms at-risk students.• Teacher stronger than fiction: troubled teens find

hope.• Education: teacher Erin Gruewell used the

Holocaust to teach students about tolerance. [Students] fill book about horrors of their own.

Diary Entry # 56

• I was getting everything off my chest and it felt damn good. I continued to tell the class that my father had molested my sister and how angry I was that my mother didn’t do anything when she found out about it.

(Freedom Writer’s Diary)

Comment demonstrates benefit “felt good”

Diary Entry # 136

• I write quotes, poems, journal entries, and stories everyday so that I can escape reality because sometimes it is unbearable.

(Freedom Writer’s Diary)

Benefit: shows a healthy escape opposed to negative coping strategies: drugs, drinking, violence, etc.

Healthy escape in moderation

• I would recommend using leisure activities for health escape in moderation.

• In example, fishing, visual imagery/ day dreaming, relaxing and other activities are beneficial.

• They could become bad if a person uses them to avoid responsibility, i.e. day dreaming and creating stories about fantasy all day opposed to working about problems.

• Balance is important.

Another benefit for journaling

• Peter Mass, a journalist for the New York Times encouraged and inspired students to continue to use writing as a form of empowerment rather then using violence.

(Freedom Writer’s Diary)

Overall, I (Danny P.) highly recommend the book: The Freedom Writers.

Who do you serve?

A. People who are suffering?B. People who have experienced physical

disabilityC. People who are from dysfunctional families? D. People who abuse drugs? E. Other? Tell me.

There is probably a book/ published journal, biography for any situation your patient may be suffering.

Dysfunctional Family

Jeanette Walls The Glass Castle

• Jeanette grew up with parents who did not have their priorities correct. They would not work. Father left child with known abuser. They would flee and move when bills piled up, yet they owned valuable property.

Was writing therapeutic?

• Jeanette Walls stated: “Writing the book was hugely therapeutic on so many levels.

(MSNBC Interview, 2005).

War, Suffering, Discrimination

Zlata Filipovic

Zlata’s Diary

She was 12 y.o. when her country Sarajevo was under attack.

She kept a journal prior to the war until she was able to leave the country as a refugee.

Was journaling therapeutic?

• Zlata said: writing was her salvation during the war and that it kept her sane. She suggested that writing might be one of the best vehicles for some of Mrs. Gruewell’s students to escape their horrific environments and personal demons.

(Freedom Writer’s Diary, 1999).

Zlata on journaling

• If I had a bad day, or I felt sad about something, and as soon as I was sad, bothered or worried, I knew where to turn to first – the diary.

• Zlata is my age: 33. She had written her diary in 1992 at the age of 12. I don’t imagine many of us in here have suffered the fate that she had at that age.

Zlata today:

• Her diary, once published allowed her an opportunity to leave the country. (a lemons into lemonade story).

• She graduated in 2001 with a B.A. in human sciences from the University of Oxford. She lives in Ireland and works to promote human rights.

Physical Disability

Bethany Hamilton.

Soul Surfer

• Bethany was a teenage surfer living in Hawaii. She grew up in the ocean. Both of her parents were surfers.

• Her arm was bitten off in a rare shark attack, first recorded in the location in Hawaii.

Was her book therapeutic?

• She had written her book with a spiritual advisor and an author.

• Bethany poured her heart out to her spiritual advisor and pastor.

• There are scientific studies that prove the healing benefits for “pouring emotions.”

Bethany today

• Bethany continues to surf today. Bethany was also featured in “Logan Magazine,” which is a magazine that profiles successful young people with disabilities.

• Logan Magazine could be great for bibliotherapy for people who work in physical rehabilitation settings.

Logan Olson comments:

• I, Danny P. had a friend request on myspace from Logan Olson, the Creative Director of Logan Magazine. I was shocked she found me because I had recently read the book Soul Surfer. (back when myspace was cool).

• Logan posted this comment: I sustained a brain injury in 2001, My RT always played UNO with me to get my hands working again. I loved my PT, OT and ST, but I had a blast with my RT.Love, Logan

• Logan said that she is living her dream by writing, creating and directing her magazine!

Drug abuse

*Go Ask AliceAnonymous

Book could offer therapeutic benefits from people in rehab trying to quit drugs/ drinking.

• Alice kept a journal during her youth. It kept a detailed record of her thoughts and feelings and the time which she began to experiment with drugs. Ultimately, she died from an overdose.

• *may be fiction

Research on journaling

• There is a growing need for evidenced-based practices. There must be proof that interventions have outcomes.

• The majority of research on the topic of journaling and the healing power of expressing emotions had been completed by James Pennebaker, PhD.

Pennebaker studied:

• People who have lost jobs

• Had spouse to recently die

• Survivors of Holocaust

• Rape victims

• New mothers

• Students from grade school to med school

Benefits

• Writing about upsetting events provides both physical and psychological benefits.

• Writing about an issue allows a person to resolve a difficult problem: divorce, death of a loved one, war, financial ruin, disability, public humiliation, etc.

• It is a basic need to express one self, rather visual arts, dance, etc. Von Gough had twisted visions or art. Hank Williams Jr. has conflicting musical themes. Writing is just one creative art for expression, like other master pieces.

Pennebaker on Benefits:

• Clears the mind• Resolves traumas • Improves memory• Increase problem-solving skills• Increases ability to cope• Increase creativity• Writing is preventative maintenance/

health promotion.

Evidence suggests:

• Writing can improve affect/ mood• Improve immune system/ improve health. • One study by Pennebaker and Ball

revealed based on blood samples taken shortly after writing, that those who had written about deepest thoughts and feelings had increase immune cells compared to those who had written about superficial topics.

Part IV

Implementing the Intervention

What you need to start?

• A journal, notebook, legal pad, or paper

• Pencil, ink pens, colored ink pens work well with children and young teens, based on my personal experience.

• A place to write.

• Time to write.

Use a timer.

• Roberta Allen (2002) suggests using a timer to help a person to concentrate/ focus her or his energy.

• Set it for 10, 15, or 30 minutes and write non-stop regardless until the timer buzzes.

• She argues that writing freely, leisurely, and spontaneously allows one’s true voice can be found. (Self-discovery).

Non-Writers?

• What if your participant/ patient does not want to write?

• According to the definition of Goodale & Godby, (1985) it is not leisure if it is “forced.”

• According to Allen (2002) one finds their true voice (self-concept) through free, leisurely writing.

Motivation Techniques

• Deci & Flaste (1995) Why we do what we do: the dynamics of personal autonomy: have a four-step process for developing internal motivation.

1. Provide a rationale for the behavior, in this case: writing.

2. Acknowledge the person’s feelings3. Invite them to try4. Allow them to make the choice.

Internal vs. External Motivation

• Deci & Flaste (1995) are opposed to rewarding a person for completing an appropriate behavior because this puts the focus on the external “getting a reward” opposed to the internal “enjoying the behavior: in this case: writing.”

• The behavior, writing, in this case should be the real reward.

The Real Reward

• Anne Lamott (1994) in her book: Bird-by-bird: some instructions on writing and life argues that a person should enjoy the process of writing (internal motivation) opposed to being focused on getting published (external reward) because those who write for the money often create work that is phony to the reader. The reader wants a real piece of creative art, which can only be created by one who loves to write.

Lemons into Lemonade

• If you’ve had a bad experience (lemons) and you’ve gained power over these issues from therapy, why not publish your story (and maybe earn a profit/ lemons). Of course, I’d never push a person towards doing going that far.

• In the two Virginias there is a healing through art festival: http://www.healingthroughcreativity.org/

Too much to write?

• What if your patient/ client argues that they have to many experiences, too much bad to write?

• Use the bird-by-bird technique by Lamott (1994).

• She had to write a report on birds and her father told her: Anne, just do it bird-by-bird, in other words, one at a time.

Activity # 1

• Let’s play a little game.

• First, I want to give thanks to Hal Urban for special written permission to re-use this activity.

• Select any 3 words from the sheet.

• Use each of the 3 words in a different sentence at the bottom of the sheet.

• How do these words make you feel?

Activity # 2

• Complete the same process with these words.

• Select any 3 words from the list

• Use the 3 words, each in a different sentence at the bottom of your paper.

• Were these sentences more positive?

The purpose of this activity?

• To understand the positive effects of words in our life.

• It does not matter if you say it or think about it or don’t think about it, the fact that the word crosses your mind, you have thought about it.

• Focus on the positives.

Positive words mean:

• An increase in the number of positive words in a person’s journal could demonstrate an increase in a more positive attitude.

Elderly and use of words

• Experiment: Willing people who are elder were randomly selected and sent to one of two rooms to learn instructions for test.

• In room 1: the instructor used words like: weak, puny, fragile, forgetful.

• In room 2: the instructor used words like: smart, experienced, strong willed, etc.

• They were told to walk down hall to a different room to complete activity.

The real test

• There was not a major activity in the room down the hall.

• They timed how long it took for the person who was elder to walk down the hall.

• Which group do you think walked minutes faster?

• Naturally, those who had the instructor who used positive words.

To increase positive attitude

• I have my patients to keep a “Grateful Journal.” One x per week.

• It is a scrapbook, which they keep pictures, drawings, stickers, quotes, and items that they are grateful for.

• They can open their book anytime to increase positive feeling of being grateful.

• Technique is great for psych facilities.

Positive Words Indicate…

Positive Reflections Journal Entry• According to (Pennebaker, 1990) an

increase in positive words is an indicator of an increase in health.

• A moderate number of negative words is an indicator of good health.

• Very high and very low levels of negative words is an indicator of poor health. Low because person is avoiding truth.

Adaptive Techniques

• This is a learning objective!

• Poor grip: Use a pencil grip, or get a small nerf ball and push the pencil/ ink pen through the middle to allow the person a better grip.

• Use a tape recorder. Expressing emotions via speaking can be beneficial as well.

Example

• I had a little boy who refused to speak about his abuse issues with his individual counselor.

• I am pleased to acknowledge that it was the recreation therapist who helped him to open up and start talking about his abuse through a creative/ self-expression project, which they designed their own life comic book.

E + R = O Technique

• Technique taken from Jack Canfield, author of The Success Principles and co-creator of the Chicken Soup Series.

• Event: An event happens• Reaction: A person has a cognitive choice

about how they re-act to the event. • Outcome: According to your cognitive

chosen reaction – you have an outcome. • To change outcome – change reaction.

Let’s try it out

• Event: If I were to say so-and-so is ugly• How many people would say that would

lower her self-esteem? • Did you pay attention to: E + R = 0 ? • She could change her Response and

think: “That is an interesting comment, but I don’t agree. I think I am beautiful. He is very focused on me and he probably thinks I’m attractive.” Outcome: positive.

The backwards comic

• He drew amazing pictures, but his comic was backwards.

• He had written and drew pictures about his mother being on crack, the men who would sexually abuse them at the crack house, and picking up cans on I-64 to recycle in order to buy food for self and younger brother.

Manga Technique

• The boy told me that he was making his comic correct and that I (Danny P.) did not know anything about comics.

• I grew up with Batman, Spiderman.

• He grew up with Manga and Japanese art.

• He introduced his book to me. His book was interesting that it read: “Property of: Kanawha County Public Library.”

Is drawing therapeutic?

The story of “Sparky”

by Earl Nightingale

Featured in Chicken Soup for SoulNightingale is also the author of

The Strangest Secret Recording

And is considered to be the founder of

The self-help field.

Who was Sparky?

• Charles Shultz. • Creator of Charlie Brown, Snoopy, the Peanuts.

Any medium can work

• Writing/ Journaling / life story

• Painting pictures

• Puppet shows/ drama

• Drawing pictures/ comic books

The Outline for a trauma narrative

• Chapter 1: All About Me • Chapter 2: Before the bad event happened:

things I liked to do, good memories • Chapter 3: The bad event that happened • Chapter 4: Me now, what I’ve learned from

therapy• Chapter 5: My life goals • Consult with mental health therapist trained in

trauma-focused CBT

Part V

Evaluating Outcomes

Wrap-up

Comments? Questions?

Complaints? Compliments?

Complete evaluation!

Contact Information

Danny Pettry

Email: Danny@dannypettry.com

Website: www.DannyPettry.Com