The benefits of journaling.

Kathleen O'Connell Chesto began a journal at midnight in intensive care when she was admitted to the hospital unable to breathe on her own in a multiple sclerosis exacerbation; Risking Hope (1990) won a Christopher Award for artistic excellence in a work affirming the highest values of the human spirit. Anatole Broyard's Intoxicated by My Illness a New York Times Notable Book of the Year, includes journal notes from May to September 1990 chronicling his terminal illness from prostate cancer Oliver Sacks carefully journaled his hospital surgery and convalescence after a hiking injury; later he exquisitely detailed physical rehabilitation and the meaning of recovery in his autobiographical A Leg To Stand On (1984). Iolene Catalano whispered and sang her life story into a microphone as she lay dying of HIV/AIDS in a nursing home; she left behind her audio-journal All the Way Broken (1995) which aired on National Public Radio. Beverly Bryant, a renowned gymnastics judge, journaled her rehabilitation and recovery from traumatic brain injury capturing the elusive experience of the injured brain 1n Search Of Wings (1992). All of these journal keepers narrated their personal, subjective experience of illness or trauma; their accounts give the reader a vivid sense of being there. These accounts reflect contemporary uses of storytelling and narrative as powerful tools of insight and change.

Readers of these illness accounts come "experience near" (Kleinman, 1996) to the universal feeling of human loss and vulnerability. Readers who attain "experience near" understanding of illness and disability may become more action sensitive in their practice of giving care. Or readers may understand how journaling one's experience of illness can be therapeutic. This article presents selected findings from therapeutic recreation (TR) research which describe techniques of journaling in an acute physical rehabilitation setting. Practical suggestions are offered for applications of journaling by other therapeutic recreation specialists (TRS).

Journaling, An Innovative Approach For TR

Journaling, as a specific form of narrative activity, is a distinct immediate expression of subjective personal experience unbound by any writing convention. It may be words, symbols, scribbles, stamping, or doodling. Journaling for personal growth and creative expression has evolved in the 20th century thanks to psychology (Carl Jung, Marion Milner AKA Joanna Field, and Ira Progoff) and literature (Anais Nin). A journal has been described as "a personal book in which creativity, play and self therapy interweave, foster, and complement each other ... a unique unrepeatable story of self' (Rainer, 1978).

The Creative Journal approach was originated by art therapist Lucia Capacchione (1989) as a picture/word diary to process her own life-threatening illness. Capacchione has designed a series of journaling books which provide exercises in exploration of feelings, self assessment, goal planning, and wellness--familiar lifestyle issues to every TRS and consumer. Journaling offers an innovative approach to helping across diverse settings in TR because of its unlimited potential for meaning-making. The unique and elevated role of TR as facilitation of meaning has been re-emphasized by external Commission on Accreditation of Rehabilitation Facilities (CARF) team members (Richter and Kaschalk, 1996). They suggested "existential outcomes" for TR rather than copying functional outcomes of other therapies:

Therapeutic recreation is about purpose and meaning, those things that make life worth living in the first place. The therapeutic recreation specialist can help people kind and insert meaning into the substance of their lives. The future of therapeutic recreation, therefore, rests primarily in existential outcomes. (Richter and Kaschalk, 1996).

Journaling is primarily a body/mind/spirit (metaphysical) activity where the journal keeper makes sense of living. It offers promise as a unique benefit that enlarges medicine's focus on "fixing the broken part" to whole-person healing.

The simple act of recording in a journal what is happening in an illness experience, including feelings and reactions, and reviewing it with a witness, makes hidden meanings in life more visible (Nealon, 1993). When TR participants and their TRSs discover what is at stake in living through patient-centered activity of emotional depth, the resulting sense of self-understanding and being understood can be liberating (White and Epston, 1990). Journals and diaries have been used successfully as clinical tools by therapists to monitor identity, mark a continuum of development or recovery and integrate and strengthen what happens during therapy (Hymer, 1991). A TRS can facilitate journaling by participants in all kinds of settings to (a) generate insight through self-reflection about reactions to an illness/disability experience; (b) explore options for thinking, acting and coping with clinical issues that arise when discussing daily experience with a therapist; (c) reveal persons' unique and individual stories/progressions through a rehabilitation experience; and (d) process feelings regarding rehabilitation and illness (Pardeck, 1991). The TRS acts as a guide and witness as the journal keeper pays attention to, and makes sense of, immediate experience.

Journaling can be facilitated as part of a holistic healing model approach during physical rehabilitation because it emphasizes participants as capable of self-responsible goal seeking. It can also reveal individual belief systems, values and subjective meanings of illness that the TRS needs to understand in order to offer individualized, meaningful help. Ten years ago, Howe-Murphy and Charboneau (1987) noted that TRSs aligned themselves with the traditional medical model rather than with holistic approaches. Today, however, alternative approaches to healing and attaining quality of life are flourishing as medical providers and alternative health providers, such as licensed massage therapists, collaborate in giving care. It is time for TR to embrace a holistic approach.

A Creative Journal of Rehabilitation as a Research Container

From 1994 to 1996, I completed dissertation research in therapeutic recreation partially supported by an NTRS research grant. I engaged in a new type of research (rarefy performed in TR) called "lived experience research" or phenomenology (Van Manen, 1994) with an acknowledged holistic perspective (Murray, 1997). The purpose of this kind of research is to come to deep understanding of the meaning or essence of some kind of human experience. Lived experience research uncovers what is taken-for-granted in daily living in order to give direction to more sensitive practice. Five research participants on a physical medicine and rehabilitation (PM&R) unit used a Creative Journal of Rehabilitation as the research container of their experience of acute physical rehabilitation and recovery. Together we literally researched, in a collaborative manner, what living through acute physical rehabilitation meant to them as a human experience.

The model used for this research (Munhall, 1994a, 1994b) encouraged the use of the following activities which I incorporated as Creative Journal of Rehabilitation components (a) interviews where participants discussed their sense of body, relationships, space, and time with me as they marked a journal page titled "My Daily Experience in Rehab," or they re-read and discussed with me journal entries written by them or their therapists as progress notes; (b) participant observation in therapy gyms and on the PM&R unit recorded in my own field note journal; (c) art made by participants on journal pages where they expressed themes of rehabilitation and recovery; (d) literature that verified participants' experiences with other first-person accounts/journals of physical rehabilitation and recovery; and (e) film as digital photographs of participants captioned and saved as Creative Journal pages to describe, verify and understand the essence of an acute rehabilitation experience.

Each participant was given a three-ring plastic binder personalized with a rainbow cover insert (e. g., Belle's Creative Journal of Rehabilitation) and a monthly calendar page. The notebook held a zippered bag of color markers, pens, gluestick, and scissors, convenient to use on a hospital tray table when confined to bed. The notebook also contained blank pre-formatted journal pages with headings like "Conversations with My Doctors" or "Today in [Physical, Occupational, or Recreation] Therapy," copies of the daily rating scale, and open-ended thematically captioned blank pages for making art. Some of these captions such as "My Body is Saying to Me" were used with written permission of Capacchione (1994); others such as "Things On My Mind" were my own captions, and/or participants could create their own captions. All participants signed consent forms and authorized the use of their artwork and journal writing for educational purposes. Participants were invited to carry their Creative Journals to therapy gyms and to self-record progress, or ask therapists to record it, on designated journal pages. Four participants consistently asked their therapists to write progress notes in their journals. Later in the day, I reviewed these entries with participants during recorded interviews. On alternate days, participants completed art expressions which they interpreted during recorded interviews.

"Stories Are Medicine"

Anatole Broyard (1992) journaled, "People bleed stories." Jungian analyst and storyteller Clarissa Pinkola Estes (1994) declared, "Stories are medicine." These claims describe the eagerness and benefit of storytelling as part of creative journaling in this research. Each participant related the story of her PM&R admission in a recorded interview. Participants relayed an identity of trauma such as:

* Lucy's physical challenge from a multiple sclerosis exacerbation, "My body's on strike--muscles went bluey on me and I'm gettin' 'em back again;"

* Kimberly's leg amputation and pylon training, "I buried an old friend and found a new one;"

* Daryn's memory loss from presumed encephalitis, "It's like being a newlywed, I'll make new memories;"

* Hailey's pain from a fall which broke the knee of her newly amputated leg, "When Frank [broken knee] wakes up, he says horrible things;"

* Belle's immobility from contractures caused by rheumatoid arthritis and a C-2 corpectomy resulting in the use an electric wheelchair and the nickname "Speed Racer."

Throughout hospital stays spanning seven to 43 days, participants remade their identities as persons recovering from illness or trauma by making coherent narratives in daily creative journal activities. Lucy, Kimberly, Daryn, Hailey, and Belle expressed an entire biography of loss and vulnerability from chronic illnesses and multiple hospitalizations as they journaled what was medically problematic to them now (intense pain, enduring the pressure 'of a pylon, muscle fatigue, memory loss, or being dependent).

Telling and writing their experience was important. Some journal entries focused on progress notes by participants, such as Daryn's notes about physical therapy, "Actually walked for the first time. Did pretty good. Rode exercise bike--too tough." Some progress notes were written by therapists, such as a physical therapist's full-page motivational collage for Belle as "Mayor of Physical Therapy." Other journal entries by participants expressed feelings about family relationships (Daryn wrote of her husband, "He's what's getting me through this") or caregiver relationships (Halley recorded "emotionally conflicting information" from her doctors).

Three of five participants consented to digital photographs in their Creative Journal. I carried an Apple Quicktake digital camera to therapy gyms and the PM&R unit and used "process consent" (Munhall, 1994b) to negotiate each photograph. Seeking hospitalized participants' consent to every research encounter/activity as "process consent" respects their momentary right to refuse, reconsider, or to collaborate given their tenuous conditions and environments (rather than researchers relying on original informed consent). Ability to laser print photographs on my home computer enabled "same day service" with copies for participants' journals. Kimberly captioned every photograph with meaningful and sometimes humorous comments in her journal stating, "They all pertain to my life." Her photographs added credibility to her story narrative and included, for example, donning and doffing a pylon, working out at therapy stations, and gardening, making crafts, and social dining as TR activities.

All participants stated that marking subtle daily change by looking back to where they had come from was important. All described various benefits of journaling as therapeutic.

* It allowed observation of change when coming through bad times.

* It personalized what was immediately important.

* It was an outlet for emotions.

* It kept a focus on personally valued goals and motivation, "made me feel good that I was doing something" and "gave me something to do besides sit around and mope."

* It distracted from pain and discomfort.

* It created memories for future reflection.

Belle summarized the empowering benefit of journaling during hospitalization:

These are my words. Nobody had a gun drawn on me and said, 'Look, we want to hear your story about rehabilitation.' This time in the hospital was really an experience. You could vent your frustrations,you could set goals for yourself just by doing this `rating yourself daily.' I enjoyed the therapists writing in the journal every day because that really gave me an incentive to motivate me. I enjoyed discussing it with you at the end of the day... it brought a lot out of me. My whole life is here.

"Art In Medicine"

Art therapist Shawn McNiff (1992) declared, "Art is medicine." Art was a significant and evolving dimension of every Creative Journal of Rehabilitation. Each participant expressed a singular style of art expression--a visceral representation of the meaning of her acute situation. Journaled drawings made participants' stories coherent with their personalities.

Daryn recognized and preserved her sense of self before memory loss by collaging pictures of food she remembered liking. Her artwork emphasized her preoccupation with appearance in a precise arrangement of symmetrical images stating, "I'm a neat freak." Lucy disdained her art expressions as "chicken-scratches" laughing, "I'm no Vincent [VanGogh] but they still held the meaning." Her line drawings revealed the effect of muscle paralysis. Her artwork magnified the isolation of her disability (MS) and its resulting preoccupation--she was alone in every one of the six drawings in her Creative Journal of Rehabilitation.

Kimberly's artwork marked integration of identity as a woman with an amputation. She journaled acceptance by stating, "Drawing it makes it more real," and humanized the multiple parts of a pylon with a colorful tennis shoe and color-coded stump socks. Hailey individualized drawings by using her own colored chalks as a medium. Her interpretation of realistic sketches of her pets created self-realization of her stated identity as "a soother and a nurturer" (ability) contrasted with hated dependence on her family, "I'm just this person who is sick or needs care" (disability).

Belle's severe contractures provided a challenge in creating artwork. We made collages with her verbally directing me to place selected magazine images on a page. Belle was delighted when her PTs, OTs, and TRSs became playfully competitive adding full-color illustrated progress notes to her Creative Journal, which became a publicly circulated document of co-treatment. For example, her OT aligned functional goals for Belle (turning the pages of her journal with a pencil grip) with Belle's self-articulated goal of some day writing her memoirs.

Making art was often surprising and sometimes unfolded spontaneously. Hailey rendered chalk drawings at night to cope with intense knee pain. Kimberly made progressive pencil sketches of her pylon and then created a full color drawing. Her description of creating artwork was reminiscent of Czikszentmihalyi's (1990) seminal notion of leisure and suggested that Kimberly had a self-creating leisure experience from journaling, "In the hospital I couldn't even sleep ... I don't know what you call it, something flowing!"

Cautions For Facilitating Journaling

Journaling is a powerful emotional activity that needs to be facilitated with ethical care (Beer, 1985). It is a difficult and demanding activity because the TRS must take care not to psychoanalyze journal keepers' writing and drawing; interpretations should be left to creators respecting them as authorities of their illness experience. While the TRS can empower participants or "encourage them to find themselves interesting and take themselves seriously" (Schiwy, 1994, p. 250), psychological insight must not be mandated. Participants come to accept and integrate illness/disability in their own time and on their own terms. In my research, it was fascinating that many profound insights from journal keepers occurred at night when I was not present. The TRS must make room to let self-discovery occur without exerting too much control or dictating formulaic ways to journal. Therapists accustomed to more control as interventionists might consider a role of supportive witnessing during non-judgmental review of journals: "The greatest gift we can give one another is rapt attention to another's existence" (Ebaugh, 1982, January 7th entry). This extends to the design of journals which can range from extremely open-ended to extremely structured. Design of journal content could be a collaborative effort between participants and a TRS and/or other members of a treatment team including family members.

Using journals as outlets for negative emotion is a delicate issue if the confidentiality of the journal cannot be secured by its owner. However, the notion of secrecy related to journals and diaries is being reconsidered. For example, family therapists have used a common diary left on a dining table for entries by family members as a strategy for conflict resolution. Journals can be used effectively as collaborative documents and chronicles, as Belle's journal was among the rehabilitation team, when they are explained and agreed to for this purpose. All five participants prized written feedback as reassurance from their from their rehabilitation caregivers.

Getting Started with Journalistic

A sensible beginning might be to examine existing journals written by persons in a designated illness or disability category such as those cited at the beginning of this article. A representative list of sources has been provided including techniques for journaling and therapeutic uses by specific populations, including mail and phone sources for enthused readers. Lucia Capacchione's The Creative Journal (1989) or The Well-Being Journal (1989) can be found in better bookstores and both have universal applications for TR settings. Capacchione suggests that making art can be astoundingly powerful; she recommends that therapists complete her exercises themselves before trying them with participants (personal communication, 1994). Her journaling books include panoramic techniques and examples of journal keepers' writing and artwork. They can be shared with participants as examples of what journaling can look like, ranging from full color drawing to simple doodling or writing.

A TRS might visit a bookstore to examine how popular illustrated and blank journals are formatted for varying interest groups, as well as the cost of journals. Pre-formatted journals might be purchased in bulk as attractive and inviting incentives for participants to journal as part of a structured TR program. Bill Zimmerman's Make Beliefs is an inexpensive "coloring playbook that draws out emotions and feelings that are hard to verbalize" (1987). Journal keepers write, draw and color new possibilities, by completing, for example, "Make Believe You Had Wings to Fly, Where Would You Go With Your Life?" Such a journal might make ideal "homework" or a positive bedtime ritual for adolescents in treatment or residential settings. Breast cancer survivors were invited to create their own nature journals at a weekend camping retreat ATRS might gather an assortment of paper, cardboard, bindings such as rocks/twigs/ string ties, and used magazine or calendar artwork to laminate as covers for handmade journals. Video or audio journals could be explored as adapted or preferred formats. Journal making/journal keeping can facilitate benefits of friendship and creativity as camping activity for children, teens, and adults with disabilities.

A TRS might review literature on the clinical, educational, and research applications of journaling (references available from the author). Journaling can be useful for assessment, leisure education, or as structured individual or group recreational writing. Assessment activity can be adapted as journaling that is multicultural with a technique explained in Magazine Photo Collage (Landgarten, 1993). Consumers tell stories about collages they make using magazine pictures that represent their various racial and ethnic groups. For example, participant Kimberly created a journal page titled "Amazing Grace" with images of women's spirituality she clipped and captioned from a black women's magazine that I deliberately provided. Pictures of black women "praising" expressed Kimberly's insistence that her own spirituality was essential in making sense of her amputation and illness.

Popular magazines are usually representative of distinct yet subtle cultural values (such as relationships, food, or activity) that a TRS might take for granted in her own culture. A TRS could easily facilitate leisure education journals tailored to an individual or group by using appropriate worksheets or exercises that address attitudes, values, skill-building, and resources, all as insight into living more effectively. Finally, the TRS might initiate or collaborate in designing journals as tools for journeys of current or future meaning-making with their participants. For example, nurses, social workers, and chaplains collaborated at Children's Mercy Hospital in Kansas City, Missouri to create Our Children Live Forever In Our Hearts: A Memory and Comfort Book (1992) for pediatric patients with terminal illnesses and their families.

Richter and Kaschalk (1996) noted an insecurity of role in the TR profession. They implored the TRS to perceive a "very singular and unique importance" as the only discipline in rehabilitation that "actually stands as an end, not just a means."Journaling is an activity that can be an end in itself as self-creating expression by participants. It can also be a means to mark and react to progress made along with medication, therapy and nurturing care. Participants' prior self-recognition may be alienated by chronic illness or severed by trauma. Journaling provides a way for the TRS, as a helper in rehabilitation or other health and human service settings, to facilitate acts of self-acknowledgment useful to participants in making sense of their situation. Journaling can help to integrate ability/disability into participants' identify and can help them realize revitalization in their recovery and in daily living.

RELATED ARTICLE: RESOURCES FOR JOURNALING

TECHNIQUES FOR JOURNALING

Kathleen Adams, Journal to the Self: Twenty-Two Paths to Personal Growth, New York, NY: Warner Books, 1990.

By Lucia Capacchione: -The Creative Journal: The Art of Finding Yourself, 1989. - The Well-Being Journal, 1989. - The Picture of Health: Healing Your Life with Art, 1990.

Martin Kimeldorf, Pathways to Leisure: A Workbook for Finding Leisure Opportunities, Bloomington, IL: Meridian Education Corporation, 1989.

Helen Landgarten, Magazine Photo Collage, New York, NY: Brunner/Mazel, 1993.

Shereen LaPlantz, Cover to Cover: Making Beautiful Books, Journals & Albums, Asheville, NC: Lark Books, 1995.

Bill Zimmerman, Make Beliefs, Guarionex Press Ltd, 201 West 77th Street, Suite 6AA, New York, NY, 10024, 1987. Call [phone].

THERAPEUTIC USES OF JOURNALING FOR SPECIFIC GROUPS

ADDICTIONS

Friends in Recovery, The 12 Steps: A Way Out, San Diego: Recovery Publications, 1987.

Jane Evans Latimer, Living Binge-Free: A Personal Guide to Victory Over Compulsive Eating, Boulder: Living Quest, 1988.

Patty McConnell, A Workbook for Healing: Adult Children of Alcoholics, New York: Harper & Row, 1986.

Geneen Roth, Feeding the Hungry Heart, New York: New American Library, 1982.

ADOLESCENT'S EXPERIENCING VIOLENCE OR GRIEF

James Oshinksy, The Discovery Journal, Psychological Assessment Resources, P.O. Box 998, Odessa, FL, 33556, 1991. Call Toll-Free 1-800-331-8378.

Ellen Traisman, Fire In My Heart Ice In My Veins: A Journal for Teenagers Experiencing a Loss, Centering Corporation, 1531 N. Saddle Creek Road, Omaha, NE, 68104, 1992. Call [phone].

BRAIN INJURY

By Beverly Bryant: - In Search of Wings: A Journey Back From Traumatic Brain Injury. [Audiotape or book format superb for sharing with clients], Wings Publishing, 1 Clifford Court, South Paris, ME, 04281, 1992. Calle [phone]. - To Wherever Oceans Go, [Family and therapist accounts of living with brain injury], 1996.

GRIEF AND BEREAVEMENT 

Rainbow Connection, The 1996 Rainbow Collection: Hand-picked Resources to Help People Grow Through Grief and Loss (catalog). Rainbow Connection, 477 Hannah Branch Road, Burnsville, NC, 28714. Call [phone].

HIV/AIDS

National Public Radio, September 9, 1995, All Things Considered, "All The Way Broken--The Life Story of Iolene Catalono", [audiotape/transcript] Washington, D.C.: NPR.

MULTIPLE SCLEROSIS

Kathleen O'Connell Chesto, Risking Hope, Kansas City, MO: Sheed & Ward, 1990.