Self-writing as a tool for change: the effectiveness of a psychotherapy using diary

Abstract

There is an abundance of literature investigating the relationship between self-writing and well-being in cases of trauma or life-changing events, but no such research has assessed the value of keeping a daily diary in promoting small changes, describing an individual’s identity in its slow, but realistic evolution. This study examined how the use of diary as a narration tool contributed to improving a patient’s awareness of his personal emotions and feelings during a course of psychotherapy. It investigated the changes occurring in the prevailing writing style of a 200-page diary written by a patient suffering from hypochondria over a period of two and a half years. Sentences relating to the need for change, to the self, to suffering and to the function attributed to the self-writing activity were analyzed on the basis of specific criteria deriving from dialogical self theory, which conceptualizes ways to adopt new identity positions during the course of change. Respondent validation identified a good correspondence between the findings of the textual analysis and the writer’s own point of view. Results showed an improvement in awareness of moods and feelings. Identity positions became more integrated and writing more enjoyable. These findings demonstrate the potential of innovative use of diary writing as a longitudinal tool for consolidating strategies for change and as an additional means for assessing psychotherapy efficacy. Writing a diary proved effective both in supporting the patient’s personal reflections and changes and in making it easier for him to share his thoughts with the therapist.

Introduction

Can self-writing contribute to personal well-being?

The assumption that storytelling is a natural human activity that helps people to better understand themselves and their experiences has been widely investigated in the literature on psychotherapy (Dominguez et al., 1995; Pennebaker & Beall, 1986; Petrie, Booth, Pennebaker, Davison, & Thomas, 1995). While writing about themselves, people reorganize biographical events to make them consistent with the present and integrate their thoughts and emotions (Bruner, 1990, 2005, 2010). Their interest in telling their story is associated with the need to revisit and reinterpret past events, and to justify emotions and feelings, to make them rational and appropriate (Bruner, 2010).

It has been demonstrated in a clinical setting (Smorti, Pananti, & Rizzo, 2010) that writing and rewriting personal stories increases an individual’s sense of control over the past (Pennebaker & Seagal, 1999). Painful events that have not been structured into a narrative may leave people continuously ruminating on negative thoughts and feelings. Pennebaker (1997) initiated a line of research devoted to clarifying the effects of expressive writing about traumatic or stressful events, and the psychological and physiological mechanisms activated by putting these events into words. Studies showed that, when people write about episodes of emotional upheaval, there is a marked improvement in their physical and mental health. Benefits to health and behaviour have been reported in people from different social classes and ethnic groups (Pennebaker & Beall, 1986; Petrie et al., 1995). Writing or talking about painful emotions can positively influence certain physical and immunological factors (Pennebaker, Kiecolt-Glaser, & Glaser, 1988). Writing also seems to be more effective than forms of bodily expressions, such as dance or other types of movement. As Krantz and Pennebaker demonstrated (1995), it is the verbalization that makes the difference. On the other hand, writing may initially have the effect of generating negativity and distress in the first few hours after putting pen to paper, especially if the writer is describing traumatic events. More positive feelings can develop as time passes, however (Pennebaker, 1997). There are also certain clinical conditions (such as depression) for which writing may not always work very well by itself (Stroebe & Stroebe, 1996). Written emotional disclosure may become a source of suffering when it induces the person to dwell on the negative value of some experiences in a redundant way, without succeeding in moving beyond their channeled negative thoughts by drawing comparisons with some different points of view.

Some studies compared writing with talking in the psychotherapy setting, and the results suggested that these different forms of expression produce much the same effects (Donnelly & Murray, 1991; Murray, Lamnin, & Carver, 1989). Another question that warrants more scrutiny regards the quality and features of an individual’s speaking or writing. It has been found, for instance, that the more people use positive terms, the more they benefit, whereas the use of language with negative connotations points to health issues (Pennebaker, Mayne, & Francis, 1997).

Self-writing as a one-off or long-term activity in psychotherapy

Most published studies on self writing in the sphere of psychotherapy follow the approach initially proposed by Pennebaker: first patients are urged to write about an autobiographical topic; then some baseline biomedical or psychological measurements are taken (T0); and, after a while (T1), both the writing activity and the measurements are repeated. Studies have seldom considered the effects of prolonged or continuous writing activity. They mainly investigated the benefits of brief periods of expressive writing. Psychotherapy is concerned with inducing small changes that fit into people’s daily lives and slowly orient them towards new ways of living and interpreting events. Most psychological disorders are expressed and develop day by day in the patient’s life experiences. As Bamberg and Demuth (2016) put it, developing and changing the feeling towards oneself should balance temporal continuity and discontinuity, and consist more of micro-processes and events within the context of relationships (small stories, situated practices in everyday social interactions) than of big moments and revolutionary biographical events.

Among the clinical studies on the changes induced by daily writing, it is worth mentioning the one by Smorti, Pananti and Rizzo (2010), who asked patients diagnosed with psychosis to keep a long-term diary. Writing helped the patients to create many autobiographical connections between their life events. They proved capable of writing about themselves. Their writing style improved with time and their personal stories gradually became more coherent, integrated and sensible. Dimaggio, Salvatore, Azzara, and Catania (2003) also analyzed how changes took place during psychotherapy by means of a qualitative microanalysis of diaries written by their patients, which also described what was happening to the therapeutic relationship at the time. This is a different perspective from the one generally taken in the literature - which considers the diary as a record of activities, thoughts and beliefs (Hyland, Kenyon, Allen, & Howarth, 1993; Mackrill, 2007, 2008) – as the diary serves as a map on which a patient can chart his self-territory. The continuity of the writing activity seems to be important in modifying a patient’s self-perception as a valid writer and storyteller.

Theoretical framework

This study is embedded in a constructionist theoretical framework within a narrative approach and refers specifically to the Dialogical Self Theory of Hermans and Kempen (1993), which offers a concept of multiple identities comprising different positions in a dialogue, and sometimes contradicting one another (Faccio, 2011; Faccio, Bordin, & Cipolletta, 2013; Faccio, Nardin, & Cipolletta, 2016; Salvini et al., 2012). The self can be described as a small society in which the citizens are called I-positions or voices (Hermans & Dimaggio, 2004).

In our study, the construct of voice was applied to the writing output, intended as a position of the writer’s identity, in our analysis of the text produced by our patient. We considered not only the two principal voices (that of the writer, and that of the protagonist he described in his diary), but also various recurrent self-description modalities, or attitudes to the self, the clinical problem, and the patient’s relationships with others. Each character (or Iposition, or personal perspective) emerged through the daily written words, evoking everyday life events, situations or personal moods. Different I-positions prevailed in different periods. Analyzing the changing I-positions is a good way to investigate changes in the writer’s selfrepresentation over time (Hermans & Kempen, 1993).

The present study

We considered the diary from a longitudinal perspective, as a narration tool for improving our patient’s awareness of his personal identity, and his control over his emotions and feelings, when it accompanies the therapeutic process, and is read and discussed with the psychotherapist.

Much attention was paid to the linguistic devices characterizing the narratives, which can reveal changes in a writer’s self-representations. In particular, we examined: i) the patient’s narrative (re)constructions and transformations in describing his clinical problem; ii) changes in the narrative relating to the patient’s personal positions throughout the process, the emergence of different voices, and the main adjectives used; and iii) changes in the patient’s attitude to the function served by his writing during his therapy.

We used qualitative and quantitative criteria to analyze the texts, also comparing our findings with the patient’s point of view.

Methods

The case story

The corpus analyzed consisted of a patient’s daily writings over a period of almost two years (January 2013 to November 2014), and an autobiography written in 2016. The therapist suggested a diary as a notebook in which the patient could write freely about anything he considered significant (The most important thing that happened during the day). The patient brought his diary to the psychotherapy sessions. The therapist read and commented on parts of it during their meetings, then photocopied the text at the end of each encounter.

The use of this material was made possible by a collaboration with a trained psychotherapist with a socioconstructionist approach. The patient, a man 50 aged (given the pseudonym of Luciano) had applied for psychotherapy to cope with his hypochondria and panic attacks. He was chosen for our study because of the particular nature of his clinical problem: his need to monitor his health made him speak anxiously to anyone about his symptoms of a disease, and how to check them. The therapist suggested that he put his need to speak into writing in an effort to reduce the boomerang effect of people asking him about his health problems, which often exacerbated his anxiety. His willingness to undertake the writing project was another necessary condition for his enrolment.

The psychotherapy lasted for two and a half years of meetings held weekly or twice a week in the first year, and less frequently during the second. At the end of the path, the psychotherapist suggested that Luciano write an autobiography as a strategy to resume and bring together all the important moments of his life, and to reconstruct the ways in which change had been achieved. The proposal was accepted by Luciano.

Data analysis

More than 16,000 words from approximately 200 pages of text were analyzed.

Two researchers (FT and EF) began by reading the whole corpus to identify the most frequently recurring content and the stylistic elements characterizing the text. Then two researchers (FT and AI) decided on the steps to complete in the text analysis, and a third (EF) guided and supervised the drafting of this article. The corpus was analyzed by comparing the selected criteria (that will be explained later) across three periods: the first (T1) corresponded to the pages written in the diary during the first year of therapy (2013), consisting of 6568 words; the second (T2) covered the pages written during the second year of psychotherapy (2014), and consisted of 6380 words; and the third (T3) concerned the autobiography written in 2016, which contained 3445 words.

The analysis was conducted page by page, taking a longitudinal perspective, and lengthy periods of writing (one year) were considered in order to identify shifts and changes in self-representation. The text produced in the first and second years was comparable in size (word number). The text produced in T3 consisted of a number of words corresponding to about half of T1 and T2, and was analyzed on the basis of the same criteria.

A circular method (Elo & Kynga, 2007) was used to analyze the content of the diary: the researchers chose four categories of elements in the text, as described below, based on the previously-presented theoretical background, and also on the features of the writing.

Transformative dimension

This is the term used to describe all elements of the text that refer to a personal resignification process. They show the writer’s attempt to interpret his experiences and attitudes from different standpoints, and to orient himself towards the desired change, or to avoid an attitude associated with the persistence of his clinical problem. The transformative dimension is evoked by modal verbs (e.g. need, must, want), especially when expressed in the conditional tense (I should control my fears and get my life back, I should improve my self-esteem; I need to limit my checking behaviour).

Identity positions

To recognize and explore I-positions in the text, we chose a specific pattern of discourse analysis in order to identify any linguistic variations that might indicate a transition from one position to another (Potter & Wetherell, 1987). Our inquiry focused on the tense structure at syntactic level (Van Dijk, 1998), and on categories such as personal pronouns, possessive adjectives, verb tenses and forms, adverbs of time, etc. In particular, a negative perspective was marked by the frequent use of negative adjectives associated with the patient’s concerns, personal inadequacies, and fears, and verbs formed with the particle not and in the first person singular. The patient’s gradual adoption of a more positive position was marked by stronger references to the future, the use of more positive adjectives, nouns such as future, next week, tomorrow, the presence of a shared perspective (the repetition of we), and of verbs in a positive form. The patient’s writing explicitly about the therapy was marked by personal pronouns, nouns and adjectives (my or myself) that often coincided with profound reflections (my problem lies in my wanting to change myself and my way of doing things too quickly; sometimes it’s difficult for me to recognize myself).

Adjectives

We considered all the adjectives, descriptive terms, expressions and manners of speech that the writer used to describe himself or his experiences in a given context. The researchers analyzed the frequency of use of these adjectives, their qualitative content, their mutual connections, and how their use changed over time.

The function of writing

To identify what personal meaning and function Luciano attributed to his writing over time, the researchers considered all his explicit and direct references to his writing activity, such as: I’m too sad to write today; or it’s like homework.

After completing their text analysis, the researchers conducted an interview with the patient to test the correspondence between the findings of their textual analysis and the writer’s own point of view, and to assess the consistency of their conclusions from Luciano’s perspective. This methodological step refers to the strategy known as respondent validation (Hill et al., 2005), according to which the validity of a study can be judged in relation to the participants’ agreement with the researchers’ findings.

Ethics

Ethical approval for the study was obtained from the Ethics Committee at the University of Padua, thus ensuring that conditions of confidentiality, anonymity and nondeception were met.

Results

All the textual constructs considered as search criteria were classified by two independent examiners (FT and EF), based on their semantic content (Green, 2004). The level of inter-rater agreement, measured with Cohen’s Kappa coefficient, was 0.90 for the transformative dimension, 0.89 for the recognition of I-positions, 0.93 for adjective classification, and 1.00 for the function of writing. In the event of discrepancies, the examiners jointly agreed on the final encoding.

Transformative dimension

The researchers identified four main issues regarding the production of new meanings related to the goals associated with the psychotherapy.

During the first year of therapy (T1), Luciano wrote about looking for new strategies to control what he called my rigid, trapping thoughts, which forced him to think constantly about his fear of death, solitude, and his own inadequacies (I must understand how my brain works and change these patterns, but now it’s not that simple. Now I’m living in constant confusion, and there are no fixed points, T1, p. 9). Over time, this rigid way of thinking never disappeared, but Luciano gradually began to consciously recognize it and learned to control it. By the end of T1, he could acknowledge his negative thinking patterns (I’m not okay today. I feel trapped in my usual routine and worries, and when this happens my bad thoughts about being ill emerge. But I know this and try to avoid it, T1, p. 116).

In the last month of T1 and during T2, a second theme appeared: the need for social relationships. While in T1 there was a sense of defeat when Luciano compared himself with others, his efforts to improve his social skills and an initial awareness of his more positive personal attitude enabled him to feel an increasing sense of competence. By the end of T2, he wrote: I have to set myself rules to manage these situations better. Today I understand that other people aren’t always confident and happy, either. Maybe they feel scared too. This gives me a little hope (T2, p. 106).

In his writings during T2, another important topic emerged: Luciano’s fear of having a serious illness and not being able to find a doctor competent enough. By the end of his therapy, this pattern of thoughts had been modified by his need to acknowledge and deal with other sources of stress (work, job, wife) that made him shift his attention from his body to other things.

In T3, after concluding the therapy, a final theme that emerged related to the patient’s need for change. He wrote about memories of his youth and his relationship with his parents. During the course of the therapy and in the years that followed, Luciano’s sense of loss, frustration and regret faded, and he judged that his difficulties were due to a lack of parental care. But instead of considering this as his destiny, he began to see it as an incentive to test his capacity for change. This change of attitude enabled him to become aware of how his mind worked, producing doubts that could not be solved. So he fought these obsessions, and his healthy part began to get angry with his other, weak and fearful part.

Identity positions

From the text analysis, the researchers identified three main voices, three I-positions adopted by the writer, that became more integrated over time.

Throughout T1, the first, and most prevalent, rigid Iposition was the most negative and passive. This I-position made Luciano feel incapable of coping with any difficulties. He saw his own shortcomings and weaknesses as insurmountable.

I am so scared and I can not see the future. I see every new symptom as a worsening of my health condition and I see the end getting closer and closer. I can not believe that anxiety can do all that (T1, p. 15). I always go forward with the thought and I can not live the moment. I always think the worst things. I have difficulty talking with people, I take offence at the slightest hint of a negative comment (T1, p. 25).

When he took this perspective, Luciano attributed only negative characteristics to himself, and he was scared of any changes that might interfere with his rigid and stable order. The core element of this voice was represented by a wholly negative meaning-making process, a way of interpreting any topic or life experience as black or white. This I-position slowly became less pervasive towards the end of T1.

Today I was a bit better than usual. I’m afraid to write it because things can change. (T1, p. 54).

Another I-position emerged and persisted throughout the remaining corpus of writing, thanks to the emergence of what the researchers called a reflective voice. In metaphorical terms, this voice may be represented as an eye that was watching, commenting and mediating Luciano’s thoughts and acts. It enabled self-observation from a third person perspective (My mind needs to be controlled because it always needs new stimuli: when life is a little monotonous, it invents them, T2, p. 32). When this perspective emerged, Luciano focused on aspects related to his therapy, and to building real hypotheses about himself and his identity.

It’s been too many years since my head has though a certain way and changing is not easy because there are some well-oiled mechanisms and that is why I find it hard to accept. That’s why I’m reticent about doing new things, but maybe it’s time to change. (T2, p. 23).

The only solution is to throw myself into new situations and maybe, in time, I will also be able to appreciate them. Now it’s all about doing things even reluctantly, hoping for better times. (T2, p. 41).

A third I-position slowly began to emerge, largely during the second year of diary writing. It started when Luciano succeeded in attributing positive capabilities to himself. He began to adopt strategies for dealing with other people, getting into relational games, and enjoying the presence of others. This position was characterized by a more realistic attribution of his strengths and weaknesses and helped him to accept himself in a growing number of situations. I feel a little more sure of myself, of my chances, and my ability, but It takes very little to change my judgment of me. (T2, p. 54).

We went to the restaurant (with my family) and although it was very busy, I was quiet, I even made the waitresses laugh, it was great! (T2, p. 67).

The emergence of this voice made Luciano more inclined to consider change as a tangible opportunity for gaining in well-being. In the latter half of T2, the presence of this voice became more and more stable, with the support of the reflective voice that helped the patient integrate his negative and positive attitudes.

In T3, this reflective I-position took control of the narrative, leaving only a little space for the other I-positions. The story was autobiographical, so the writer was focused not on his thoughts or experiences at the time, but on memories of his recent past, and this perspective led him to constantly adopt a self-observational standpoint. You can only see these events if your mind is free, and if you gain more awareness of who you are. I now see the world with other eyes. I see things in more depth. I am like a curious child who discovers something new every day. (T3, p. 17).

Adjectives

Luciano’s writing contains many descriptions of himself, his experiences and his thoughts. These linguistic elements were analyzed both qualitatively (examining the content, and the positive and negative connotations from Luciano’s point of view, as emerged from the text) and quantitatively (the frequency of use of certain adjectives). All the adjectives compared in T1, T2 and T3 were classified into eight categories (Green, 2004) based on their semantic content, as shown in Table 1.

In T1 Luciano made use of only a few, mainly negative adjectives (Today I’m worried, nothing is good, and I feel ‘defeated’; I’m still ‘unmotivated’. Around others I always feel ‘weak’ and ‘unfit’).

Table 1.

Macro-categories of adjectives used by Luciano and their value connotations.

Macro-categories of adjectives	Examples of adjectives in this category	Connotation
Adjectives related to concern	Concerned, preoccupied, worried	Negative
Adjectives related to emotional stress	Agitated, upset, restless, stressed, troubled	Negative
Adjectives related to anxiety	Anxious, nervous	Negative
Adjectives related to personal difficulties	Incapable, unable, incompetent, defeat	Negative
Feeling of diversity	Different from others	Negative and positive
Feeling of strangeness	Strange, mad, wrong	Negative and positive
Person who has qualities	Sensible, clever, tenacious, happy, competent	Positive
Tranquillity	Quiet, calm, relaxed, peaceful	Positive

The adjectives used in his T2 writings have a different, more positive connotation and are more varied. It was interesting to see that the first positive terms Luciano used to refer to the psychotherapy relationship, that was initially a primary source of negative adjectives. Luciano began to use positive words in describing his memories or experiences in which he experienced satisfaction (My swimming lesson made me feel ‘satisfied’. My teacher was nice. I think she considered me a ‘kind’ person; Last night was funny, my friend and I went out to dinner and I felt ‘almost happy’). There were more proactivity and a desire to become the protagonist in his story, and this new role was characterized by hitherto unexpressed feelings of anger.

In T3, the researchers found an increase in the number of positive adjectives that Luciano used about himself and his life (It was hard for me to see myself as a ‘clever’ person because people always judged me as stupid, but I’ve succeeded in seeing some ‘positive aspects’ of my character and my soul now).

Comparing the adjectives (in macro-categories) used in the three periods (T1, T2 and T3) revealed a declining frequency in the use of negative adjectives over time; see the categories concern, agitation, and anxiety, for instance (Table 1). Adjectives relating to feelings about personal difficulties diminished from T1 to T2 then stabilized in T3. Meanwhile, there was a growing sense of diversity and strangeness (see the tranquillity category) that emerged gradually from T1 to T2 to T3. The only surprising finding relates to the person with qualities category (Table 2).

The data presented in Table 1 suggest a narrative evolution in Luciano’s writing from the initial prevalence of negative words to an increasing use of more positive terms. T3 deserves a special mention because it is a summary of Luciano’s life. The first adjectives used have a negative connotation because they are linked to his adolescence and refer mainly to the negative ways in which Luciano had interiorized his life at a time when others saw him as strange, different, and mad (see the diversity category in Table 1). Page after page, these attributes change and become linked to a personal and positive opinion of himself: Luciano begins to describe himself as intelligent, tenacious and confident (see the person with qualities category in Table 1). The biographical reconstruction characterizing Luciano’s writing in T3 would justify the persistence of negative adjectives in the first part and their replacement by a more reassuring and favourable self-representation in the second.

The function of writing

The researchers identified an evolution in Luciano’s feelings about his writing activity. Throughout T1, he saw it as homework assigned by the therapist (Today I don’t know what to write, I’m writing many times the same things, I’m repetitive, but I don’t have others ideas, T1, p. 67). During T2, he began to comment on feelings of well-being he experienced that were related to his writing, which slowly became a personally useful tool for expressing his deepest thoughts, beliefs, and most painful reflections. Today I’m feeling better. I’m scared to write this because I think this positive feeling could also change; I have a lot of thoughts, the best chance I have of understanding them is by impressing them on these pages (T2, pp. 29, 35). These sentences clearly point to some of the functions of keeping a diary in Luciano’s experience: it enabled him to reorder his thoughts and to unburden his mind by putting some bad feelings or memories into written words. Writing and rewriting was a useful exercise for Luciano because he could outsource events, get bored, rewrite them in the same or a slightly different way, and remove some of the powerful negative parts, all of which facilitated a process of self-awareness.

In T3 this process appears to have become consolidated. Luciano continued to write on his own even after the end of the psychotherapy, and he produced his autobiography. He described the act of writing as my safe place where I can throw all my thoughts, fears or achievements, […] an important part of my personal life.

Respondent validation

Analyzing the answers Luciano gave during his interview (Flick, 2014) revealed a correspondence between the above-presented findings and Luciano’s perception of the changes occurring during his therapy. Some additional content emerged too. Luciano confirmed the importance of the themes that emerged in the transformative dimension, and how they evolved (his rigid thoughts at the outset, his need for social relations, his worrying about his bodily health, and the re-emergence of his past). He highlighted the centrality of the relational component, which he experienced both as a fear of being judged and as a source of pleasure when he realized he had some social skills.

Table 2.

Numbers of adjectives used by Luciano during each writing period (T1, T2, T3).

Macro-categories of adjectives	T1 (6568 words)	T2 (6380 words)	T3 (3445 words)
Adjectives related to concern	18	13	1
Adjectives related to agitation	12	10	8
Adjectives related to anxiety	17	10	9
Adjectives related to personal difficulties	16	11	11
Feeling of diversity	8	6	11
Feeling of strangeness	7	7	8
Person who has qualities	7	10	3
Tranquillity	3	6	7

Concerning the changes in the dominant I-positions and adjectives used in describing himself, Luciano said: When fear dominated me (the first I-position), I felt like a mouse trying to hide in the corner, but When I could escape the fear, I could see things in a more rational way, and I realized that it was just me making up all the risks and all my doubts (the second I-position). He went on to say: With time, I realized that I had some qualities and that others weren’t always perfect and better than me (the third I-position). Luciano’s change of attitude to his writing seemed consistent with his own perceptions too. Importantly, this change in his approach to self-writing was facilitated by Luciano’s relationship with his therapist, as Luciano himself emphasized during the interview.

Another finding concerns Luciano’s revisiting the origins of his problems. He was convinced that his sense of loneliness was at the root of all his irrational fears: Loneliness, not having relationships, not getting in touch with people, this is what led me to form certain thoughts [...]. He felt that the therapeutic relationship enabled him to overcome this problem because it was non-judgmental and showed humanity, and he was not treated as crazy (as some members of his family had described him).

Evolution and connection between the search criteria

The outcomes show a concomitant evolution in the four criteria considered. In T1, the negative descriptions of the transformative dimension of Luciano’s suffering overlapped with the emergence of the first I-position. Then, throughout the diary (T1 and T2), the transformative dimension was sometimes represented by a shift from negative to positive events associated with the relational experience. This second step coincided with the emergence of a reflexive I-position: Luciano gradually became more aware of his suffering, its origin and possible meaning. Regarding the second criterion, the researchers recognized a reduction in the patient’s body-related fears and monitoring of his behaviour, and a return to his daily activities. Luciano initially wrote nothing about his qualities, but he slowly learned to interpret his story in a less rigid way, using new descriptions of himself and different standpoints. The four criteria seemed to be strongly intertwined.

Discussion

Our analysis has taken into consideration many narrative components in order to investigate the evolution of the patient’s identity representation. All the linguistic elements considered – the contents of the transformative dimension, the evolution of identity positions, the adjectives, and the function attributed to writing – have been seen to follow a similar and parallel evolution in the three phases of the psychotherapeutic path, moving from a problematic, redundant formulation to a more positive one. From a clinical point of view, it is very interesting to notice that the emergence of the second I-position (the reflexive one), which allowed the patient to become more aware of his thoughts, of their vicious circle and their evolution, fitted very well with his need to take control over the situation in a broader sense. His clinical problem (his anxious and pervasively negative mood, reflected in his hypochondria and panic attacks) was linked to the fear of losing control, as revealed also by the first issue that emerged in the analysis of the transformative dimension: the need for control over his rigid thoughts. Maybe this explains why the writing activity could represent a core strategy, since it was devoted to self-observation and to enhancing the writer’s reflexive ability, which was the aim of the psychotherapy and also what the patient most wanted to achieve.

By our findings, daily diary writing proved effective both in supporting personal reflections and changes and in facilitating the patient’s sharing of his thoughts with the therapist. It was also effective as a tool for capturing the micro-transformations in Luciano’s identity that emerged day by day, page after page, reflecting how change usually occurs during therapy and in the real life (Bamberg & Demuth, 2016). In the clinical setting, patients’ self-narratives can further therapists’ understanding of their patients and shed light on the argumentative logic they use to describe themselves and their problems. In our case, gaining knowledge of Luciano’s convictions and attitudes relating to the transformative dimension, and recognizing his dominant I-positions proved fundamental to the conduction of his psychotherapy and the choice of therapeutic goals. Sharing the findings that emerge from a text analysis may also be a strategy that therapists can use to give patients evidence of changes that have already occurred. A diary can provide a very good picture to enable comparisons between past and present. As Dimaggio et al. (2003, p. 157) put it, reading and rereading forces patients to maintain their experiences in their working memory. This exercise, if repeated over time, creates a screen on which to contemplate one’s actions. It enables reflection on different possible reactions, unhindered by the negativity of the emotion experienced in vivo. The diary writing and therapeutic relationship may then work towards the same goal of promoting self-reflexivity.

Text analysis can also support and orient the assessment of psychotherapy as the writing provides so many elements that help us to understand the patient’s evolution during the course of psychotherapy. This could pave the way to a new clinical research field, with potential for development.

Therapists should bear in mind, however, that (as shown in the reports from Pennebaker & Seagal, 1999) self-writing also carries the risk of triggering strong emotions, especially when patients write about traumatic or negative events, and they may become disturbed or alarmed. If this happens, it is important to resume a less disruptive and problematic therapy and to restore serenity in the patient’s life. As with any other strategy or tool used in a clinical setting, the effects of using a diary are not always positive and depend on what it signifies to patients, and their relationship with the therapist. Another decisive factor is the patient’s attitude toward writing. Although in Luciano’s case this changed over time, proportionally with his self-esteem, it would be wrong to insist on the use of a diary for patients who say at the beginning of their therapy that they are unwilling to write one.

Limitations of the study and proposals for further research

One limitation of this study concerns our inability to distinguish between the benefits deriving from the selfwriting activity and those due to well-conducted psychotherapy. Many of the positive effects we have presented may relate to good therapeutic actions and to the quality of the relationship between the therapist and the patient – and not necessarily to the practice of writing. We nonetheless believe that this limitation can be overcome by including other questions during the final interview relating to respondent validation (Hill et al., 2005) concerning the distinction between the two domains. Asking the writer some specific questions might help clarify the effective benefits deriving from both components. This would also provide circularity between data-gathering, data-testing, and the emergence of new meanings, that the researchers may have underestimated.

Conclusions

The activity of self-writing gives the writer the chance to become both the film director and the protagonist of his or her own story. This special condition seems to be crucial for people who suffer from the inability to change their own story. Metaphorically speaking, in the clinical story presented here, the patient’s diary could be seen as a self-portrait (Smorti, 2007; Smorti & Fioretti, 2015) painted under the psychotherapist’s gaze. The identity positions associated with the patient’s problem are not as real as in an objective picture; instead, they take the shape the painter lends them. A self-portrait only has sense and value when someone else can look at it, and the therapist’s role is to enable a relational acknowledgement and confirmation of what happened during the therapeutic process. As Bruner claimed, writing is always a relational task. While it might seem to be a solitary activity, it implies the processes involved in a dialogue, with oneself and with an internalized listener.

Funding Statement

Funding: none.