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Use of the journal in treatment of the seriously emotionally disturbed adolescent: A case study
The Arts in Psychotherapy, Vol. 21, No. 3, 197-204. 1994 Copyright Q 1994 Eisevier Science Ltd Printed in the USA. All rights reserved 01974556/94 $6.00 + .OO
Pergamon 0197-4556(94)EOO25-L
USE OF THE JOURNAL IN TREATMENT OF THE SERIOUSLY EMOTIONALLY DISTURBED ADOLESCENT: A CASE STUDY?
ROBIN B. ZEIGER. PhD*
There is a relative paucity of literature on the use of journal writing in therapy as well as a highly related topic, therapeutic poetry writing (e.g., Creadick, 1985). Writing as a part of the counseling is identified as an aid in relationship building, identification of problem areas, expression of feelings and emotional temperature taking (e.g., Fulwiler, 1987). It is utilized as an adjunct to counseling with a large caseload of students (Haglund & Edet, 1985) and as a vehicle for psychodynamic change (Edgar, 1978). Two articles, which are of more direct relevance to this paper, identify the therapeutic benefits of writing with seriously disturbed patients (Abrams, 1978; Goodman & Hart, 1988). They conclude that journal and poetry writing can be extremely helpful as an adjunct to treatment in an inpatient setting. Among other benefits, writing helps patients to release anger, improve self-esteem, identify problems and develop a deeper relationship between teacher and student (Go~man & Hart, 1988). This article illustrates the use of the journal via case method. It presents journal selections from an adolescent faced with multiple emotional and behavioral problems who spent several years in a residential and day treatment program. Following each journal entry is a brief analysis of the ~e~~utic mewing of
Treating the seriously emotion~ly disturbed adolescent is often extremely challenging. As a result, multiple treatment modalities are typically utilized. These include individual, family and group psychotherapy and milieu treatment, as well as a behavioral level system. In addition, over the years, many inpatient and day and residential treatment programs have found less traditional treatment modalities, such as art, dance and movement therapy, to be extremely useful. The present article identifies some benefits of journal writing in psychotherapy with a seriously disturbed adolescent. Although there is a significant body of literature on journal writing, most is not directly relevant to treatment of the seriously disturbed. Many articles deal with the benefits of journal writing in general (e.g., Miller, 1979) or of its use as a classroom learning tool (Bowm~, 1983; Kintisch, 1986; Yinger, 1985). Several articles deal with enhanced learning in specialized populations, such as the handicapped (Farley, 1986), the learning disabled (Johnson & Hoover, 1989), the gifted (Farley & Farley, 1987), college students and psychology students (Hallberg, 1987; Hettich, 1980, 1988, 1990; McManus, 1986) and teacher training (Wodlinger, 1990).
*Robin Geiger, a licensed clinical psychologist, currently works for Jewish Family Services in Richmond, Virginia. While at The H.E.L.P. Group in Van Nuys, California, she had extensive experience as a psychotherapist, clinical supervisor and Director of Intern Training working with seriously emotionally disturbed children, adolescents and their families. Dr. Zeiger also writes a column for a local newspaper in Richmond, ?This manuscript is based on a paper presented at the Annual Meeting of the California Psychological Association and American Psychological Association, Division 12, San Francisco, CA. The author thanks Susan Berman, PhD, Clinical Director of The H.E.L.P. Group of Van Nuys, CA and Sydney Fleicher, LCSW, Director of Professional Services, Jewish Family Services, Richmond, VA, for their comments on the manuscript. 197
ROBIN B. ZEIGER the writing piece. The method of analysis employed utilizes an object relations framework (Blanck & Blanck, 1974; Kernberg, 1976; Mahler, Pine & Bergman, 1975). It is argued that the journal is an extremely useful treatment modality with this type of patient for several reasons. First, many seriously disturbed patients are ambivalent about intimacy. On one hand, they are often highly dependent and wish to be taken care of by adults. On the other hand, they have often suffered multiple rejections, separations and/or abandonments from caretakers they have become dependent upon. Thus, they may become fearful of intimacy. The journal, by virtue of the fact that it is a less intimate modality than the therapeutic encounter, can assist this patient in gradually becoming more disclosing. In addition, for the patient who is extremely needy, the journal may serve as a transitional object and/or method of more frequent contact with the therapist. For example, the patient who has difficulty separating from the therapist over weekends can hold onto and make use of the journal as a method of connection to the therapist in his or her absence. Some patients are better at expressing themselves in writing. Thus, the journal may help them to better articulate particularly dif~cult and painful topics in their treatment. The journal may also help the impulsive patient to become more reflective and insightful. For example, this modality can be incorporated into a behavioral level system of consequences. Patients then may be asked to write an essay in their journal reflecting upon an episode of acting-out. They may also be required to give this essay to the therapist, which can then aid in connecting episodes of actingout to treatment issues. Finally, the journal serves as a concrete record of the patient’s progress for both the patient and the therapist. Periodically the patient may wish to look back over the entries and reflect upon changes she or he has made. Case Description Nick was a 15-year-old adolescent with a history of serious emotional problems that included an extremely unstable childhood. Nick’s parents were separated when he was just an infant. His early years were characterized by inconsistent parenting. Much of the time he lived with his paternal grandparents. His father’s job involved a good deal of traveling. Thus, Nick only had periodic contact with him. Nick
had almost no contact with his mother, whom he described as having multiple problems of her own. At an early age, Nick began to experience severe behavioral problems, such as distractibility, impulsivity and poor social relationships. From the age of about five and a half Nick spent a good deal of time in hospital programs and residential treatment homes. He was diagnosed with an attention deficit disorder and placed on Ritalin at an early age. At one point during late latency, Nick lived with his mother for about a year. He later returned to his paternal grandparents and father. Nick remembered his early years as conflictual. He said that he did not feel particularly close to any of his relatives. During early adolescence, while living with his father and grandparents, Nick reported an increase in family conflict. He said that his father began to make many demands upon him. Nick became very angry, feeling that his father had been so previously unavailable that he had no right to set limits. Nick reacted with a good deal of acting-out, which included verbal abuse, running away several times and marijuana use. He also remembered engaging in some selfdestructive behavior (e.g., suicidal gestures such as cutting his wrist). Nick’s running away and increasingly out-of-control behavior eventually came to the attention of Department of Children’s Services. He was then placed at our facility through the court system. At admission, presenting problems included poor social skills, unstable relationships, property destruction, depression, emotional lability and some selfdestructive behavior. Nick also reported some previous sexual abuse by an adult male friend. In addition, there was a histrionic quality to Nick that included odd mannerisms designed to draw attention to himself (i.e., odd dress). When extremely stressed, Nick’s reality testing would break down and he began to focus on a belief in his “special powers” (i.e., ESP). On admission to our facility, Nick had little contact with his family. Throughout his two and a half year stay, contact with mother, father and grandparents was inconsistent. Diagnostic ~o~ceptua~i~atio~ from an Object Relations Perspective In treatment Nick presented with many complex problems. He displayed several of the typical symptoms of an attention deficit hyperactivity disorder. He
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was highly distractible, impulsive and had a difficult time concentrating, particularly in school. The Ritalin Nick was placed on was helpful in managing these symptoms. Much of Nick’s remaining pathology could best be conceptualized from an object relations framework. In 1974, Blanck and Blanck discussed the importance of a descriptive developmental diagnosis in which the therapist attempts to categorize the patient according to ego functioning. Nick had presented with extremely impaired object relations. This was evident through his immature and unstable social relationships. He approached them with a combination of narcissistic and borderline pathology. On the narcissistic end of the continuum, he was extremely egocentric and needy. He struggled with many unmet needs for recognition and mirroring of his often fluctuating emotions. Often his desire for attention manifested itself in histrionic behavior (odd dress, strange hair styles). He also spent a good deal of time attempting to convince peers and adults alike of his brilliance, unique powers (of ESP) and his overall im~~ance. These narcissistic defenses were quite brittle and thus rather poorly masked an underlying defective sense of self. When wounded (rejected by a fellow peer), Nick would easily become depressed and at times would display suicidal ideation as well as self-destructive gestures (hit hand against wall). The primitive nature of Nick’s self-concept and defensive structure suggested primarily borderline pathology. This was most notable in his frequent splitting defense. His typical approach to relationships was to vacillate between idealization and devaluation. At times, this occurred quite quickly within a short therapeutic session. Kemberg (1976) pointed out that this p~mitive splitting and comp~mentalization of the mind is a key diagnostic aspect of borderline pathology. Often it appears as if these patients have two selves, and they are not bothered by the seeming contradictions in personality (pp. 23-24). Nick’s approach to therapy spoke to his pathology. He quickly developed a strong, symbiotic relationship. The three scheduled individual appointments and two group sessions per week were not enough. He was so needy and disorganized that he frequently sought therapeutic attention outside of scheduled time. His behavior on campus was so histrionic and, at times, alarming that the daycare staff and teachers also sought the therapist frequently for advice. Initially, Nick idealized the therapeutic relationship and
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projected any anger elsewhere. He even spoke of his fear that anger at the therapist would destroy the relationship. The Initial Treatment As an example of written contact with sion to our program. with a day ~eatment
his extreme Nick came Nick shared assistant in
neediness, the first shortly after admisthe following piece his classroom.
Loneliness They must cry at the death of one so near. They must miss him. They must sigh at the one so dear. They must have loved him. He slit his wrists in the Hails of Senior Boys. His friends deserted him, and his family disowned him. Someone must love him. He could be in your back yard, but can’t hear his cries over glee. But listen, it’s there. The loneliest way to die is alone. He loves the only one he can-the one who will love him back. He hates the ones who don’t know how to love. I am the one so dear. The one so close to death, but yet so far. I love the ones who know how to love, and I hate the rest. I have few friends. I love everyone! The day treatment assistant brought this essay to me, expressing concern about Nick’s possible suicidality. When I met with Nick, he told me he had written this “poem” several months before while at a previous placement. He assured me that he did not intend to hurt himself. In analyzing Nick’s first written communication, it appeared somewhat histrionic and designed to secure more attention in the classroom. Since admission, Nick had become extremely demanding of almost constant 1:l attention from adults. In addition, he had poor bound~es and was unable to disc~minate when and where to disclose personal materiai about himself. The essay was an attempt to communicate to his current caretakers his extreme depression, pain and the futility he experienced in his life. Finally, this essay also pointed to Nick’s poor object constancy, emotional lability and primary defense of splitting, The last lines characterized Nick’s current levei of ego functioning quite well. He stated:
ROBIN B. ZEIGER I love the ones who know how to love, and I hate the rest. I have fewfriends. I love everyone! Nick had characterized The Decision
the world in extremes.
to Utilize Journal Writing
At this point in treatment, a therapeutic plan was devised that included journal writing. There were several reasons for this decision. Nick appeared extremely needy; he was struggling with any type of separation from this therapist and appeared to need a transitional object, particularly on days when there was no scheduled therapeutic contact. His preferred tendency to write offered a natural avenue as a transitional object. In addition, it was an intervention often utilized by therapists in our agency for a variety of reasons. Thus, Nick would quickly become aware that he was not the only one writing a journal and he would not feel singled out in a negative manner. Instead, it was hoped that this therapeutic intervention would build upon the patient’s ability. Nick was very proud of his writing. Like a parent who places the child’s drawings on the refrigerator, therapy would encourage Nick’s growing skill. His deprived childhood and primitive needs suggested that it was important to help build defenses, positive transference and self-esteem. There was not yet enough stable ego structure to taken an exclusively analytic approach. Of even more importance in designing the therapeutic intervention, it appeared that this type of material (about suicide) would be better dealt with if contained to therapy sessions. This would aid Nick in establishing better boundaries and decreasing splitting through helping him discriminate when and where to discuss personal material. It would also, it was hoped, aid his adjustment to the milieu. For example, Nick had already begun to alienate peers by his extreme attention-seeking from adults and his tendency to disclose much personal material of a threatening nature too quickly. Finally, it is important to add a note about my countertransference. Kernberg (1976) and others (e.g., Gorkin, 1987) have pointed out the importance of utilizing countertransference responses to understand the nonverbal communications of more primitive pathology. In Nick’s case, he quickly elicited a sense in me that I was not doing enough. He always seemed to want more. I felt I needed to work hard at containing his pathology, particularly in the milieu. The day treatment, residential treatment and school
staff often seemed to become alarmed and frustrated with Nick. They could not seem to do enough and also wanted a great deal from me. Nick was clearly communicating on a nonverbal level how very needy and disorganized his life was. He longed for a mother figure to nurture him and keep him safe much as a mother of a toddler would. He attempted to elicit this behavior from me and all of the important adults around him. His therapeutic needs were spilling out and essentially causing disorganization and some panic in the milieu. Thus, I felt both the need to provide more (attention through journal writing) as well as to better contain his issues to the treatment room. The Initial Intervention In talking with Nick after I assessed him for suicidality, I verbally reinforced his ability to write about himself. 1 then talked about the effects this essay had upon his day treatment assistant (she was greatly concerned about his safety). I suggested that this type of writing would best be dealt with in therapy. I told Nick I would be very glad to read his writings and discuss them with him. Shortly thereafter I bought Nick a notebook to use as a journal. Finally, I reinforced to Nick that, if he did write something about suicide, I would assess him to make sure he would not hurt himself. At this time I did not address or interpret Nick’s process of splitting. It appeared much too premature. Over the next few months Nick gradually began to share his writings with me. At times he gave me his journal when we did not have a scheduled appointment as a way of increasing contact and communicating his pain to me when it was too much to bear alone. Nick’s first few entries focused on love. He appeared to be searching for love from others to heal the narcissistic wounds of the past. He appeared to unconsciously long for that one symbiotic relationship in which he could forever be taken care of in a way he had never experienced as a child. At times he appeared to find this love briefly. Love Is I lie by the stillness of the waters. I wander aimlessly. I wish at the wishing well-its no how, no matter. Love is an endless abyss.
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It goes on for ever and ever. That’s like my true love. Her heart is as big as a house. That’s my true love-it’s Denise.
Denise, a young lady in the program, often attempted to care for other needy patients. She began to express concern for Nick. At other times, Nick communicated how the love was never enough. Feelings I cry at the boy who sighs-he is so lonely. I look at the way people talk. They have no message. They just laugh at him. He is so sad. Last week I tried to talk to him. He has no friends. Well I ask of you, I plead with you-be his friend. He’ll love you for it too. He is so lonely. In treatment, Nick began to struggle with how poorly he got along with peers. This was definite progress in that he could begin to more willingly dispense with his narcissistic defenses for a short time to deal with flaws. He could now verbalize his struggles in alternating between believing he was all bad, a total failure, and believing he was all good, blaming the program and his peers. In the second instance, he asked to return to his previous placement. Symbolically Nick was also beginning to communicate to me his unconscious wish to merge with me and feel taken care of like a small infant. However, it was much too early in treatment to begin to talk about these desires. Rather I attempted to help him become more attached to me and to begin to use me as an auxiliary ego, When Nick was very depressed and feeling hopeless, I began to take on the role of observing ego. I began to help him hang on desperately to the fleeting positive images he held of himself. I began to hold them up for his view, to help him make these images into a more defined picture. Slowly, but surely, Nick began to hold these positive images up for himself. He was increasingly using his writing to soothe himself. His writing included positive fantasies and dreams. I began to ally more
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and more with these images, attempting to help Nick further integrate the positive. Instead of just reading his entries, I began to answer him in writing, focusing on the process of positive internalization. Gradually, Nick became more successful in the program. For example, his peer relationships were somewhat more stable. He was also more successful with the behavioral level system, reflecting better impulse control. Yet, like many patients who have had multiple failures, it was difficult for him to believe in success. I worked with him on accepting and internalizing the success.
Confusion I lie by the sea with awesome expectation. I ponder my thoughts. My mind wanders aimlessly through the darkness and the stillness of the night. I wonder with delight in the origin of my success. Nick, What a nice poem! Congratulations on your new found success of level 2.24! Keep up the good work! Have a Happy Easter and wonderful pass with your grandparents. Dr. Z.
About eight months into treatment, Nick played a song for me about a road inside.of all of us. Up until now, Nick’s image of himself had been very dependent upon external influences, such as his behavioral level or whether he recently had an argument with a particular family member. I used this opportunity to talk about the road inside all of us and how we each work at becoming true to ourselves. Shortly thereafter, Nick wrote: There are many roads in this life. Some are long and some are short. . but the road you walk down is the road inside of you. The main road is life, and its roads are many. . . and they differ from where you go. All I ask is for you to follow your heart and go down the right road.
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202
Dear Nick, This sounds a little like the idea in the beautiful song that you played for me about the road inside. Together we can work on building the road inside . . . Keep up the good work. Dr. Z. Interestingly, this was the first poem in Nick’s second journal. It appeared to symbolize a new beginning, a newfound ability to internalize treatment and begin to integrate desperate parts of himself into a whole object. Nick was beginning to build his own road. He was becoming less dependent upon the moment. His ego, like the road, was more sturdy and had direction. As Nick’s ego began to develop, I became more interpretive. We could begin to tie the present to the past. We could begin to look at how the shifts in his image of others and himself were at least partially dependent upon his history. Pity I ask for the boy who needs it. He only gets the disappointments, and they take his trust and twist it to further their needs. He wants to trust you, but he can’t because of the disappointments. So I ask for pity. He needs it. Dear Nick, It sounds like you are struggling with how much to trust those around you. I can understand how this is such a big issue when your mother hasn’t been so trustworthy lately. Sometimes it is real easy to get hurt. Dr. Z. I continued to attempt to help Nick develop a more integrated view of himself. Likewise, he continued to struggle with integrating the bad and good images. Throughout his first year of treatment Nick often attempted to protect me from his anger. When enraged, his reality testing broke down. He feared that his anger would literally destroy me. Nick talked about past situations when his anger had taken on special powers and destroyed objects. In the past, when angry at me, he often hurt himself through sabotaging his progress or literally harming himself (hit hand on wall). Gradually Nick began to trust himself more and trust me with his anger. He began to use his journal and his
treatment to communicate and his demonic side:
his darker side-his
rage
This Is No Poem This is my first oficial non-poem. Staff are dogging me out yesterday. I got jive fails in room care and a day drop and that was for my closet and dresser tops, even though they were clean. And today, I got them for floor article pick up and put away. And at this very second, Doug is provoking me (3:21 p.m.). He is smiling at me and is moving his eyes at me. Back to the topicAnd staff don’t give a shit-Corinthian 5:53-for the perishable must clothes its self with imperishable and the mortal with immortal . . He began to bring up historic material about past acting-out and his guilt over his behavior. It was if he had both a need to confess and a need to see if he could shock me: A Dream I was running along a track, when I saw my friend sitting in the bleachers. I asked him what he was doing there and that I hadn’t seen him for many months. Then he said that we had just come from the bar over there, and he pointed to a bar. . . So we went to his old house and had a couple of beers. And then he asked me what did you mean when you said, “What are you doing here? I haven’t seen you for many months.” I said that I had been in a group home for several months. He said to go home, and so I did. My dad was nice to me at first. then he said in an evil, demonic voice, “You’ve been bad.” As he dealt with this type of material, for the first time Nick began to become enraged in my office. He expressed homicidal thoughts. At times, he even was able to become enraged at me. Nick now had enough control to contain his murderous impulses. Thus, it was finally safe to unleash these feelings. He could now dump all of his bad feelings in my office and leave feeling better. Likewise, his behavior in the milieu improved. He was less impulsive and selfdestructive (decrease in verbal abuse, absence of hand banging on the wall and minimal to no destruction of
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his own property). However, at times Nick still struggled with his negative image of himself. He continued to direct his anger inward and then became depressed. He wrote of suicidal thoughts, but once again there was little acting-out. We could now talk more about the feelings: Never Say Die Can’t you hear the boy who cries? He is so alone, Noone ever knows his disappointments. He wants to love himself, but he doesn’t know how. He wants to love others, but he can’t. Locked inside the bathroom, he grabs a razor blade, slowly slits his wrists. And that’s the end of his life. Sadness fills his family. Sorrow fills his friends. He thought he had no friends, but he was wrong. He didn’t think he had so much, but now he has no life. If only we had told him that the answer was not suicide, but life in Jesus Christ. He is life, He may be in your back yard, but you don’t even see him. His cries are lost forever. But he’s there, waiting for someone to call on him. He wants someone to love him. Someone just like you. But the boy who cries out for he can’t hear you, because he’s gone away for good. Its not too late.
The acting-out of the conflicts became more subtle and less serious. For example, Nick would wear odd clothing to communicate his need for more attention. Now I could interpret the message and we were able to talk about it. I really don’t know what to write so here goes. I had a bad day at school today. drops in schools, and I got a home. I really don’t want to subjects because they upset me. therapist!
I got two level level drop at discuss these I still love my
Dear Nick, It sounds like you are trying to calm yourself down. I’m glad about that. Maybe when we walk together you can tell me why you are so agitated. I can tell that you’re very upset because you are wearing your green shirt. I’m also happy you are feeling good about our relationship. Dr. Z.
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Nick’s writing began to take on a more integrated quality. He began to write of internal strength and of the ability to give to others: Giving and caring is the most you can do. For someone who cares is someone like you. If you see someone hurting or sad with pain, Pick them up and show them the way. Give them the gift that comes from within. Show them yourself and make them your friend.
Nick had less of a desire and need to write to me. His journal was no longer that important. Together, one day, we decided to type up his poems in a nice notebook. This served as a concrete reminder of his progress. It was a way for us to review, cherish and hold onto the road we had traveled together. Shortly thereafter he presented me with his final entry: Ltfe is a roaring ocean, and we are cast adrtft of its waves. Though we may think we know where we are in it and where we are going, we really do not. You may think you can change it, but it can’t be done or so it seems. But like the currents of the ocean, so is life. You can change your problems, but it will take lots and lots of time and effort to do this. Like the waves on the ocean, we do not know tf they are going to swell or settle. We do not know if there is going to be a storm, or if the wind will blow. We are but mortal man. We can not predict the future, but we can change it. Like some may say, ltfe is what you make it. This is true to some extent. You can’t change the way other people act and feel, but you can change yourself. So I say look within and see what you can change and what you can’t. Then after you have done this, then you can help yourself by helping others. I will leave you with one footnote. God give me the serenity and wisdom to accept the things I can not change, the wisdom and strength to change the things I can, and the wisdom to know the difference. Thank you. Nick Overall Progress
Throughout his journal writing and course of treatment, Nick made slow, steady progress in many areas. As mentioned previously, he gradually became better able to contain and/or let down his narcissistic
ROBIN B. ZEIGER defenses. Simultaneously, he was able to acknowledge and deal with some of his personality flaws. Often Nick’s first acknowledgment of an insecurity was in writing. This disclosure then helped foster verbal discussion of the topic. It seemed much easier for Nick to say something difficult in writing first. His journal writing and emerging therapeutic discussions most significantly reflected changes in Nick’s object relations. He showed a definite decrease in the defense of splitting. Gradually, Nick began to speak of gray areas in life, rather than just referring to issues as black and white. He became somewhat more realistic in his appraisal of family members, perceiving some good with the bad. Nick’s impulse control improved. He was much better able to vent anger in treatment without losing subsequent control in the milieu. He also developed some problem-solving strategies for calming himself. In spite of all this progress, Nick left the facility somewhat abruptly shortly before his eighteenth birthday. Although he was presented with the option of continued treatment and admission to a young adult program, he decided he needed to give it a try on his own. His anxiety over the dependence/independence struggle was very difficult to manage and won out over a more carefully planned discharge. Nick returned for brief visits a few times. He was able to ask for some assistance and consultation. He made some clear mistakes and struggled with his independence for a while. However, it seemed clear that his therapeutic progress helped him through the struggles. He was able to admit mistakes and to seek out therapy when appropriate. As a young adult, Nick appears much less impulsive and more realistic in his approach to relationships. He still bears the wounds of his early years and will probably always struggle with some of the same issues. Yet, his internal resources allow him to cope with life’s problems in a much more adaptive manner. Conclusion Journal writing can become a very powerful adjunct to psychotherapy with the seriously emotionally disturbed patient. In Nick’s case, his writing provided a valuable tool to connect with his therapist and to express intense feelings. The journal also served as a transitional object in the therapist’s absence. The process of analyzing the written topics in therapy helped to promote object constancy and therapeutic growth. But, perhaps most importantly, Nick expressed a
great deal of pride in ownership of the completed journal. This document symbolized a powerful statement about his struggles and ultimate growth. References Abrams, A. S. (1978). Poetry therapy in the psychiatric hospital. In A. Lemer (Ed.), Poetry in the therapeutic experience (pp. 63-71). New York: Pergamon Press. Blanck, G., & Blanck, R. (1974). Ego psychology: Theory and practice. New York: Columbia University Press. Bowman, R. F. (1983). The personal student journal: Mirror of the mind. Contemporary Education, 55(l), 25-27. Creadick, T. A. (1985). The role of the expressive arts in therapy. Journal of Reading, Writing, and Learning DisabilitiesInternational, l(3), 55-60. Edgar, K. (1978). The epiphany of the self via poetry therapy. In A. Lemer (Ed.), Poetry in the therapeutic experience (pp. 2440). New York: Pergamon Press. Farley, J. W. (1986). An analysis of written dialogue of educable mentally retarded writers. Education and Training of the Mentally Retarded, 21, 181-191. Farley, J. W., & Farley, S. L. (1987). Interactive writing and gifted children: Communication through literacy. Journal for the Education of the Gifted, 10(2), 99-106. Fulwiler, L. (1987). What’s a horny? or Writing and counseling in the middle school. In T. Fulwiler (Ed.), TheJournal Book (pp. 299305). Portsmouth, NH: BovntonXook. Goodman, G., & Hart, L. (1988). Building communication skills. Academic Therapy, 23(4), 431435. Gorkin. M. (1987). The uses of countertransference. Northvale, NJ: Jason Aronson. Haglund, E., & Edet, M. (1985). Writing as a process of counselling: The experience of two guidance counsellors in Nigeria. School Psychology International, 6(3), 175-179. Hallberg, F. (1987). Journal writing as person making. In T. Fulwiler (Ed.), The Journal Book (pp. 289-298). Portsmouth, NH: BoyntonXook. Hettich, P. (1980). The journal revisited. Teaching of Psychology, 7(2), 105-106. Hettich, P. (1988). Journal writing: An autobiographical approach to learning. High School Psychology, 29(3), 4, 67. Hettich, P. (1990). Journal writing: Old fare or nouvelle cuisine? Teaching of Psychology,17(l), 3639. Johnson, S. E., & Hoover, J. H. (1989). Use of dialogue journals with secondary learning disabled students. Academic Therapy, 25(l), 75-80. Kemberg, 0. (1976). Object relations theory and clinical psychoanalysis. New York: Jason Aronson. Kintisch, L. S. (1986). Journal writing: Stages of develoument. Reading Teacher, 40(2), 168-172. Mahler, M. S., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant. New York: Basic Books. McManus, J. L. (1986). “Live” case study / Journal record in adolescent psychology. Teaching of Psychology, 23(2), 7&74. Miller, S. U. (1979). Keeping a psychological journal. The Gifted Child Quarterly, 23(l), 168-175. Wodlinger, M. G. (1990). April: A case study in the use of guided reflection. The Alberta Journal of Educational Research. 36(2), 115-132. Yinger, R. (1985). Journal writing as a learning tool. VoltaReview, 87(5), 21-33.
Pergamon 0197-4556(94)EOO25-L
USE OF THE JOURNAL IN TREATMENT OF THE SERIOUSLY EMOTIONALLY DISTURBED ADOLESCENT: A CASE STUDY?
ROBIN B. ZEIGER. PhD*
There is a relative paucity of literature on the use of journal writing in therapy as well as a highly related topic, therapeutic poetry writing (e.g., Creadick, 1985). Writing as a part of the counseling is identified as an aid in relationship building, identification of problem areas, expression of feelings and emotional temperature taking (e.g., Fulwiler, 1987). It is utilized as an adjunct to counseling with a large caseload of students (Haglund & Edet, 1985) and as a vehicle for psychodynamic change (Edgar, 1978). Two articles, which are of more direct relevance to this paper, identify the therapeutic benefits of writing with seriously disturbed patients (Abrams, 1978; Goodman & Hart, 1988). They conclude that journal and poetry writing can be extremely helpful as an adjunct to treatment in an inpatient setting. Among other benefits, writing helps patients to release anger, improve self-esteem, identify problems and develop a deeper relationship between teacher and student (Go~man & Hart, 1988). This article illustrates the use of the journal via case method. It presents journal selections from an adolescent faced with multiple emotional and behavioral problems who spent several years in a residential and day treatment program. Following each journal entry is a brief analysis of the ~e~~utic mewing of
Treating the seriously emotion~ly disturbed adolescent is often extremely challenging. As a result, multiple treatment modalities are typically utilized. These include individual, family and group psychotherapy and milieu treatment, as well as a behavioral level system. In addition, over the years, many inpatient and day and residential treatment programs have found less traditional treatment modalities, such as art, dance and movement therapy, to be extremely useful. The present article identifies some benefits of journal writing in psychotherapy with a seriously disturbed adolescent. Although there is a significant body of literature on journal writing, most is not directly relevant to treatment of the seriously disturbed. Many articles deal with the benefits of journal writing in general (e.g., Miller, 1979) or of its use as a classroom learning tool (Bowm~, 1983; Kintisch, 1986; Yinger, 1985). Several articles deal with enhanced learning in specialized populations, such as the handicapped (Farley, 1986), the learning disabled (Johnson & Hoover, 1989), the gifted (Farley & Farley, 1987), college students and psychology students (Hallberg, 1987; Hettich, 1980, 1988, 1990; McManus, 1986) and teacher training (Wodlinger, 1990).
*Robin Geiger, a licensed clinical psychologist, currently works for Jewish Family Services in Richmond, Virginia. While at The H.E.L.P. Group in Van Nuys, California, she had extensive experience as a psychotherapist, clinical supervisor and Director of Intern Training working with seriously emotionally disturbed children, adolescents and their families. Dr. Zeiger also writes a column for a local newspaper in Richmond, ?This manuscript is based on a paper presented at the Annual Meeting of the California Psychological Association and American Psychological Association, Division 12, San Francisco, CA. The author thanks Susan Berman, PhD, Clinical Director of The H.E.L.P. Group of Van Nuys, CA and Sydney Fleicher, LCSW, Director of Professional Services, Jewish Family Services, Richmond, VA, for their comments on the manuscript. 197
ROBIN B. ZEIGER the writing piece. The method of analysis employed utilizes an object relations framework (Blanck & Blanck, 1974; Kernberg, 1976; Mahler, Pine & Bergman, 1975). It is argued that the journal is an extremely useful treatment modality with this type of patient for several reasons. First, many seriously disturbed patients are ambivalent about intimacy. On one hand, they are often highly dependent and wish to be taken care of by adults. On the other hand, they have often suffered multiple rejections, separations and/or abandonments from caretakers they have become dependent upon. Thus, they may become fearful of intimacy. The journal, by virtue of the fact that it is a less intimate modality than the therapeutic encounter, can assist this patient in gradually becoming more disclosing. In addition, for the patient who is extremely needy, the journal may serve as a transitional object and/or method of more frequent contact with the therapist. For example, the patient who has difficulty separating from the therapist over weekends can hold onto and make use of the journal as a method of connection to the therapist in his or her absence. Some patients are better at expressing themselves in writing. Thus, the journal may help them to better articulate particularly dif~cult and painful topics in their treatment. The journal may also help the impulsive patient to become more reflective and insightful. For example, this modality can be incorporated into a behavioral level system of consequences. Patients then may be asked to write an essay in their journal reflecting upon an episode of acting-out. They may also be required to give this essay to the therapist, which can then aid in connecting episodes of actingout to treatment issues. Finally, the journal serves as a concrete record of the patient’s progress for both the patient and the therapist. Periodically the patient may wish to look back over the entries and reflect upon changes she or he has made. Case Description Nick was a 15-year-old adolescent with a history of serious emotional problems that included an extremely unstable childhood. Nick’s parents were separated when he was just an infant. His early years were characterized by inconsistent parenting. Much of the time he lived with his paternal grandparents. His father’s job involved a good deal of traveling. Thus, Nick only had periodic contact with him. Nick
had almost no contact with his mother, whom he described as having multiple problems of her own. At an early age, Nick began to experience severe behavioral problems, such as distractibility, impulsivity and poor social relationships. From the age of about five and a half Nick spent a good deal of time in hospital programs and residential treatment homes. He was diagnosed with an attention deficit disorder and placed on Ritalin at an early age. At one point during late latency, Nick lived with his mother for about a year. He later returned to his paternal grandparents and father. Nick remembered his early years as conflictual. He said that he did not feel particularly close to any of his relatives. During early adolescence, while living with his father and grandparents, Nick reported an increase in family conflict. He said that his father began to make many demands upon him. Nick became very angry, feeling that his father had been so previously unavailable that he had no right to set limits. Nick reacted with a good deal of acting-out, which included verbal abuse, running away several times and marijuana use. He also remembered engaging in some selfdestructive behavior (e.g., suicidal gestures such as cutting his wrist). Nick’s running away and increasingly out-of-control behavior eventually came to the attention of Department of Children’s Services. He was then placed at our facility through the court system. At admission, presenting problems included poor social skills, unstable relationships, property destruction, depression, emotional lability and some selfdestructive behavior. Nick also reported some previous sexual abuse by an adult male friend. In addition, there was a histrionic quality to Nick that included odd mannerisms designed to draw attention to himself (i.e., odd dress). When extremely stressed, Nick’s reality testing would break down and he began to focus on a belief in his “special powers” (i.e., ESP). On admission to our facility, Nick had little contact with his family. Throughout his two and a half year stay, contact with mother, father and grandparents was inconsistent. Diagnostic ~o~ceptua~i~atio~ from an Object Relations Perspective In treatment Nick presented with many complex problems. He displayed several of the typical symptoms of an attention deficit hyperactivity disorder. He
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was highly distractible, impulsive and had a difficult time concentrating, particularly in school. The Ritalin Nick was placed on was helpful in managing these symptoms. Much of Nick’s remaining pathology could best be conceptualized from an object relations framework. In 1974, Blanck and Blanck discussed the importance of a descriptive developmental diagnosis in which the therapist attempts to categorize the patient according to ego functioning. Nick had presented with extremely impaired object relations. This was evident through his immature and unstable social relationships. He approached them with a combination of narcissistic and borderline pathology. On the narcissistic end of the continuum, he was extremely egocentric and needy. He struggled with many unmet needs for recognition and mirroring of his often fluctuating emotions. Often his desire for attention manifested itself in histrionic behavior (odd dress, strange hair styles). He also spent a good deal of time attempting to convince peers and adults alike of his brilliance, unique powers (of ESP) and his overall im~~ance. These narcissistic defenses were quite brittle and thus rather poorly masked an underlying defective sense of self. When wounded (rejected by a fellow peer), Nick would easily become depressed and at times would display suicidal ideation as well as self-destructive gestures (hit hand against wall). The primitive nature of Nick’s self-concept and defensive structure suggested primarily borderline pathology. This was most notable in his frequent splitting defense. His typical approach to relationships was to vacillate between idealization and devaluation. At times, this occurred quite quickly within a short therapeutic session. Kemberg (1976) pointed out that this p~mitive splitting and comp~mentalization of the mind is a key diagnostic aspect of borderline pathology. Often it appears as if these patients have two selves, and they are not bothered by the seeming contradictions in personality (pp. 23-24). Nick’s approach to therapy spoke to his pathology. He quickly developed a strong, symbiotic relationship. The three scheduled individual appointments and two group sessions per week were not enough. He was so needy and disorganized that he frequently sought therapeutic attention outside of scheduled time. His behavior on campus was so histrionic and, at times, alarming that the daycare staff and teachers also sought the therapist frequently for advice. Initially, Nick idealized the therapeutic relationship and
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projected any anger elsewhere. He even spoke of his fear that anger at the therapist would destroy the relationship. The Initial Treatment As an example of written contact with sion to our program. with a day ~eatment
his extreme Nick came Nick shared assistant in
neediness, the first shortly after admisthe following piece his classroom.
Loneliness They must cry at the death of one so near. They must miss him. They must sigh at the one so dear. They must have loved him. He slit his wrists in the Hails of Senior Boys. His friends deserted him, and his family disowned him. Someone must love him. He could be in your back yard, but can’t hear his cries over glee. But listen, it’s there. The loneliest way to die is alone. He loves the only one he can-the one who will love him back. He hates the ones who don’t know how to love. I am the one so dear. The one so close to death, but yet so far. I love the ones who know how to love, and I hate the rest. I have few friends. I love everyone! The day treatment assistant brought this essay to me, expressing concern about Nick’s possible suicidality. When I met with Nick, he told me he had written this “poem” several months before while at a previous placement. He assured me that he did not intend to hurt himself. In analyzing Nick’s first written communication, it appeared somewhat histrionic and designed to secure more attention in the classroom. Since admission, Nick had become extremely demanding of almost constant 1:l attention from adults. In addition, he had poor bound~es and was unable to disc~minate when and where to disclose personal materiai about himself. The essay was an attempt to communicate to his current caretakers his extreme depression, pain and the futility he experienced in his life. Finally, this essay also pointed to Nick’s poor object constancy, emotional lability and primary defense of splitting, The last lines characterized Nick’s current levei of ego functioning quite well. He stated:
ROBIN B. ZEIGER I love the ones who know how to love, and I hate the rest. I have fewfriends. I love everyone! Nick had characterized The Decision
the world in extremes.
to Utilize Journal Writing
At this point in treatment, a therapeutic plan was devised that included journal writing. There were several reasons for this decision. Nick appeared extremely needy; he was struggling with any type of separation from this therapist and appeared to need a transitional object, particularly on days when there was no scheduled therapeutic contact. His preferred tendency to write offered a natural avenue as a transitional object. In addition, it was an intervention often utilized by therapists in our agency for a variety of reasons. Thus, Nick would quickly become aware that he was not the only one writing a journal and he would not feel singled out in a negative manner. Instead, it was hoped that this therapeutic intervention would build upon the patient’s ability. Nick was very proud of his writing. Like a parent who places the child’s drawings on the refrigerator, therapy would encourage Nick’s growing skill. His deprived childhood and primitive needs suggested that it was important to help build defenses, positive transference and self-esteem. There was not yet enough stable ego structure to taken an exclusively analytic approach. Of even more importance in designing the therapeutic intervention, it appeared that this type of material (about suicide) would be better dealt with if contained to therapy sessions. This would aid Nick in establishing better boundaries and decreasing splitting through helping him discriminate when and where to discuss personal material. It would also, it was hoped, aid his adjustment to the milieu. For example, Nick had already begun to alienate peers by his extreme attention-seeking from adults and his tendency to disclose much personal material of a threatening nature too quickly. Finally, it is important to add a note about my countertransference. Kernberg (1976) and others (e.g., Gorkin, 1987) have pointed out the importance of utilizing countertransference responses to understand the nonverbal communications of more primitive pathology. In Nick’s case, he quickly elicited a sense in me that I was not doing enough. He always seemed to want more. I felt I needed to work hard at containing his pathology, particularly in the milieu. The day treatment, residential treatment and school
staff often seemed to become alarmed and frustrated with Nick. They could not seem to do enough and also wanted a great deal from me. Nick was clearly communicating on a nonverbal level how very needy and disorganized his life was. He longed for a mother figure to nurture him and keep him safe much as a mother of a toddler would. He attempted to elicit this behavior from me and all of the important adults around him. His therapeutic needs were spilling out and essentially causing disorganization and some panic in the milieu. Thus, I felt both the need to provide more (attention through journal writing) as well as to better contain his issues to the treatment room. The Initial Intervention In talking with Nick after I assessed him for suicidality, I verbally reinforced his ability to write about himself. 1 then talked about the effects this essay had upon his day treatment assistant (she was greatly concerned about his safety). I suggested that this type of writing would best be dealt with in therapy. I told Nick I would be very glad to read his writings and discuss them with him. Shortly thereafter I bought Nick a notebook to use as a journal. Finally, I reinforced to Nick that, if he did write something about suicide, I would assess him to make sure he would not hurt himself. At this time I did not address or interpret Nick’s process of splitting. It appeared much too premature. Over the next few months Nick gradually began to share his writings with me. At times he gave me his journal when we did not have a scheduled appointment as a way of increasing contact and communicating his pain to me when it was too much to bear alone. Nick’s first few entries focused on love. He appeared to be searching for love from others to heal the narcissistic wounds of the past. He appeared to unconsciously long for that one symbiotic relationship in which he could forever be taken care of in a way he had never experienced as a child. At times he appeared to find this love briefly. Love Is I lie by the stillness of the waters. I wander aimlessly. I wish at the wishing well-its no how, no matter. Love is an endless abyss.
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It goes on for ever and ever. That’s like my true love. Her heart is as big as a house. That’s my true love-it’s Denise.
Denise, a young lady in the program, often attempted to care for other needy patients. She began to express concern for Nick. At other times, Nick communicated how the love was never enough. Feelings I cry at the boy who sighs-he is so lonely. I look at the way people talk. They have no message. They just laugh at him. He is so sad. Last week I tried to talk to him. He has no friends. Well I ask of you, I plead with you-be his friend. He’ll love you for it too. He is so lonely. In treatment, Nick began to struggle with how poorly he got along with peers. This was definite progress in that he could begin to more willingly dispense with his narcissistic defenses for a short time to deal with flaws. He could now verbalize his struggles in alternating between believing he was all bad, a total failure, and believing he was all good, blaming the program and his peers. In the second instance, he asked to return to his previous placement. Symbolically Nick was also beginning to communicate to me his unconscious wish to merge with me and feel taken care of like a small infant. However, it was much too early in treatment to begin to talk about these desires. Rather I attempted to help him become more attached to me and to begin to use me as an auxiliary ego, When Nick was very depressed and feeling hopeless, I began to take on the role of observing ego. I began to help him hang on desperately to the fleeting positive images he held of himself. I began to hold them up for his view, to help him make these images into a more defined picture. Slowly, but surely, Nick began to hold these positive images up for himself. He was increasingly using his writing to soothe himself. His writing included positive fantasies and dreams. I began to ally more
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and more with these images, attempting to help Nick further integrate the positive. Instead of just reading his entries, I began to answer him in writing, focusing on the process of positive internalization. Gradually, Nick became more successful in the program. For example, his peer relationships were somewhat more stable. He was also more successful with the behavioral level system, reflecting better impulse control. Yet, like many patients who have had multiple failures, it was difficult for him to believe in success. I worked with him on accepting and internalizing the success.
Confusion I lie by the sea with awesome expectation. I ponder my thoughts. My mind wanders aimlessly through the darkness and the stillness of the night. I wonder with delight in the origin of my success. Nick, What a nice poem! Congratulations on your new found success of level 2.24! Keep up the good work! Have a Happy Easter and wonderful pass with your grandparents. Dr. Z.
About eight months into treatment, Nick played a song for me about a road inside.of all of us. Up until now, Nick’s image of himself had been very dependent upon external influences, such as his behavioral level or whether he recently had an argument with a particular family member. I used this opportunity to talk about the road inside all of us and how we each work at becoming true to ourselves. Shortly thereafter, Nick wrote: There are many roads in this life. Some are long and some are short. . but the road you walk down is the road inside of you. The main road is life, and its roads are many. . . and they differ from where you go. All I ask is for you to follow your heart and go down the right road.
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Dear Nick, This sounds a little like the idea in the beautiful song that you played for me about the road inside. Together we can work on building the road inside . . . Keep up the good work. Dr. Z. Interestingly, this was the first poem in Nick’s second journal. It appeared to symbolize a new beginning, a newfound ability to internalize treatment and begin to integrate desperate parts of himself into a whole object. Nick was beginning to build his own road. He was becoming less dependent upon the moment. His ego, like the road, was more sturdy and had direction. As Nick’s ego began to develop, I became more interpretive. We could begin to tie the present to the past. We could begin to look at how the shifts in his image of others and himself were at least partially dependent upon his history. Pity I ask for the boy who needs it. He only gets the disappointments, and they take his trust and twist it to further their needs. He wants to trust you, but he can’t because of the disappointments. So I ask for pity. He needs it. Dear Nick, It sounds like you are struggling with how much to trust those around you. I can understand how this is such a big issue when your mother hasn’t been so trustworthy lately. Sometimes it is real easy to get hurt. Dr. Z. I continued to attempt to help Nick develop a more integrated view of himself. Likewise, he continued to struggle with integrating the bad and good images. Throughout his first year of treatment Nick often attempted to protect me from his anger. When enraged, his reality testing broke down. He feared that his anger would literally destroy me. Nick talked about past situations when his anger had taken on special powers and destroyed objects. In the past, when angry at me, he often hurt himself through sabotaging his progress or literally harming himself (hit hand on wall). Gradually Nick began to trust himself more and trust me with his anger. He began to use his journal and his
treatment to communicate and his demonic side:
his darker side-his
rage
This Is No Poem This is my first oficial non-poem. Staff are dogging me out yesterday. I got jive fails in room care and a day drop and that was for my closet and dresser tops, even though they were clean. And today, I got them for floor article pick up and put away. And at this very second, Doug is provoking me (3:21 p.m.). He is smiling at me and is moving his eyes at me. Back to the topicAnd staff don’t give a shit-Corinthian 5:53-for the perishable must clothes its self with imperishable and the mortal with immortal . . He began to bring up historic material about past acting-out and his guilt over his behavior. It was if he had both a need to confess and a need to see if he could shock me: A Dream I was running along a track, when I saw my friend sitting in the bleachers. I asked him what he was doing there and that I hadn’t seen him for many months. Then he said that we had just come from the bar over there, and he pointed to a bar. . . So we went to his old house and had a couple of beers. And then he asked me what did you mean when you said, “What are you doing here? I haven’t seen you for many months.” I said that I had been in a group home for several months. He said to go home, and so I did. My dad was nice to me at first. then he said in an evil, demonic voice, “You’ve been bad.” As he dealt with this type of material, for the first time Nick began to become enraged in my office. He expressed homicidal thoughts. At times, he even was able to become enraged at me. Nick now had enough control to contain his murderous impulses. Thus, it was finally safe to unleash these feelings. He could now dump all of his bad feelings in my office and leave feeling better. Likewise, his behavior in the milieu improved. He was less impulsive and selfdestructive (decrease in verbal abuse, absence of hand banging on the wall and minimal to no destruction of
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his own property). However, at times Nick still struggled with his negative image of himself. He continued to direct his anger inward and then became depressed. He wrote of suicidal thoughts, but once again there was little acting-out. We could now talk more about the feelings: Never Say Die Can’t you hear the boy who cries? He is so alone, Noone ever knows his disappointments. He wants to love himself, but he doesn’t know how. He wants to love others, but he can’t. Locked inside the bathroom, he grabs a razor blade, slowly slits his wrists. And that’s the end of his life. Sadness fills his family. Sorrow fills his friends. He thought he had no friends, but he was wrong. He didn’t think he had so much, but now he has no life. If only we had told him that the answer was not suicide, but life in Jesus Christ. He is life, He may be in your back yard, but you don’t even see him. His cries are lost forever. But he’s there, waiting for someone to call on him. He wants someone to love him. Someone just like you. But the boy who cries out for he can’t hear you, because he’s gone away for good. Its not too late.
The acting-out of the conflicts became more subtle and less serious. For example, Nick would wear odd clothing to communicate his need for more attention. Now I could interpret the message and we were able to talk about it. I really don’t know what to write so here goes. I had a bad day at school today. drops in schools, and I got a home. I really don’t want to subjects because they upset me. therapist!
I got two level level drop at discuss these I still love my
Dear Nick, It sounds like you are trying to calm yourself down. I’m glad about that. Maybe when we walk together you can tell me why you are so agitated. I can tell that you’re very upset because you are wearing your green shirt. I’m also happy you are feeling good about our relationship. Dr. Z.
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Nick’s writing began to take on a more integrated quality. He began to write of internal strength and of the ability to give to others: Giving and caring is the most you can do. For someone who cares is someone like you. If you see someone hurting or sad with pain, Pick them up and show them the way. Give them the gift that comes from within. Show them yourself and make them your friend.
Nick had less of a desire and need to write to me. His journal was no longer that important. Together, one day, we decided to type up his poems in a nice notebook. This served as a concrete reminder of his progress. It was a way for us to review, cherish and hold onto the road we had traveled together. Shortly thereafter he presented me with his final entry: Ltfe is a roaring ocean, and we are cast adrtft of its waves. Though we may think we know where we are in it and where we are going, we really do not. You may think you can change it, but it can’t be done or so it seems. But like the currents of the ocean, so is life. You can change your problems, but it will take lots and lots of time and effort to do this. Like the waves on the ocean, we do not know tf they are going to swell or settle. We do not know if there is going to be a storm, or if the wind will blow. We are but mortal man. We can not predict the future, but we can change it. Like some may say, ltfe is what you make it. This is true to some extent. You can’t change the way other people act and feel, but you can change yourself. So I say look within and see what you can change and what you can’t. Then after you have done this, then you can help yourself by helping others. I will leave you with one footnote. God give me the serenity and wisdom to accept the things I can not change, the wisdom and strength to change the things I can, and the wisdom to know the difference. Thank you. Nick Overall Progress
Throughout his journal writing and course of treatment, Nick made slow, steady progress in many areas. As mentioned previously, he gradually became better able to contain and/or let down his narcissistic
ROBIN B. ZEIGER defenses. Simultaneously, he was able to acknowledge and deal with some of his personality flaws. Often Nick’s first acknowledgment of an insecurity was in writing. This disclosure then helped foster verbal discussion of the topic. It seemed much easier for Nick to say something difficult in writing first. His journal writing and emerging therapeutic discussions most significantly reflected changes in Nick’s object relations. He showed a definite decrease in the defense of splitting. Gradually, Nick began to speak of gray areas in life, rather than just referring to issues as black and white. He became somewhat more realistic in his appraisal of family members, perceiving some good with the bad. Nick’s impulse control improved. He was much better able to vent anger in treatment without losing subsequent control in the milieu. He also developed some problem-solving strategies for calming himself. In spite of all this progress, Nick left the facility somewhat abruptly shortly before his eighteenth birthday. Although he was presented with the option of continued treatment and admission to a young adult program, he decided he needed to give it a try on his own. His anxiety over the dependence/independence struggle was very difficult to manage and won out over a more carefully planned discharge. Nick returned for brief visits a few times. He was able to ask for some assistance and consultation. He made some clear mistakes and struggled with his independence for a while. However, it seemed clear that his therapeutic progress helped him through the struggles. He was able to admit mistakes and to seek out therapy when appropriate. As a young adult, Nick appears much less impulsive and more realistic in his approach to relationships. He still bears the wounds of his early years and will probably always struggle with some of the same issues. Yet, his internal resources allow him to cope with life’s problems in a much more adaptive manner. Conclusion Journal writing can become a very powerful adjunct to psychotherapy with the seriously emotionally disturbed patient. In Nick’s case, his writing provided a valuable tool to connect with his therapist and to express intense feelings. The journal also served as a transitional object in the therapist’s absence. The process of analyzing the written topics in therapy helped to promote object constancy and therapeutic growth. But, perhaps most importantly, Nick expressed a
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