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
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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 selfexpression 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 Assessment
Social
Physical
Affect/
Emotion
Spiritual
Cognitive
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 Plans
By 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
disability
C. 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 Alice
Anonymous
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 evidencedbased 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:
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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:
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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
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Deci & Flaste (1995) Why we do what we
do: the dynamics of personal autonomy:
have a four-step process for developing
internal motivation.
Provide a rationale for the behavior, in
this case: writing.
Acknowledge the person’s feelings
Invite them to try
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 cocreator 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 Soul
Nightingale 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
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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