Jane Raleigh, Clinical Specialist in Rheumatology, Dorset County Hospital
Meherrzerin Das, Principal Clinical Psychologist, Dorset HealthCare NHS Trust

In this talk Jane Raleigh described a piece of research that she undertook in partial fulfilment for a masters qualification. In her cross sectional questionnaire-based study she compared emotional processing in women with fibromyalgia (FM) with emotional processing in healthy female controls and in women with rheumatoid arthritis (RA).

Jane started off her presentation with some general background information about fibromyalgia. Fibromyalgia syndrome (FM) is a disorder of widespread myalgia, increased sensitivity to mildly noxious stimuli, poor, non restorative sleep and generalised fatigue. She noted that there is considerable debate in the literature regarding the aetiology of fibromyalgia.

Jane pointed out that while FM is an increasingly common diagnosis in rheumatology outpatient clinics, existing management/treatment strategies yield poor long term results.

She noted that individuals with FM have often experienced significant emotional trauma in their lives prior to the onset of their symptoms. Evidence has indicated that individuals with FM may have some deficits in emotional processing (EP), tending to misattribute the symptoms of emotional arousal to solely somatic causes.

Jane went on to describe the samples that she recruited into her study.

§ Group 1: Individuals with FM attending the outpatient rheumatology clinics of either Dorset County or Poole Hospital (N=52).

§ Group 2: Individuals with rheumatoid arthritis attending the out-patient rheumatology clinics at Dorset County Hospital (N=34)

§ Group 3: Healthy individuals recruited from staff working at Dorset County Hospital (N=53).

Baker’s emotional processing scale (EPS) was used as a measure of emotional processing.

Jane then went on to describe the results from the studies. Here, we provide a summary of the main findings that she presented:

§ The FM group had significantly higher overall scores on the Emotional Processing Scale indicating greater overall difficulties in emotional processing than either the healthy group or the RA group.

§ The FM group also had significantly higher scores on most of the subscales of the EPS than either of the two other groups.

Overall the FM group demonstrated:

§ a more impoverished style of emotional style of emotional processing

§ more emphasis on physical orientation towards emotion

§ more suppression of emotions and their expression

§ greater inability to control the expression of emotion

Jane concluded by noting that her study highlights the role of emotional processing factors in an FM population and supports a need for psychological input in the assessment and treatment of the condition.

Fibromyalgia: the clinical picture of a mind-body conundrum

Meherzin Das’s insightful presentation was clinically oriented. She suggested her ideas lie midway on a continuum between a generalizable model (‘one size fits all’) and an individualised model (the ‘perfect fit’). Her reflections derived from psychological assessment, psychological therapy, cognitive behavioural and cognitive analytic models as well as data from the Psychotherapy File.

Meherzin noted that in the FM patients she treats there is often a recognisable history of parental patterns (such as only offering conditional care, being over demanding/neglectful/abusive). Such parental patterns can lead to maladaptive reactions and styles in children.

Meherzin described insights she has obtained from using the Psychotherapy File assessment tool:

§ Traps: fear of hurting others/appeasing/can’t say no/perfectionism/difficulty expressing emotions/feeling criticised/feeling responsible/anxious/ <give up< over-control.

§ Snags: Sabotage by external events

§ Dilemmas: Submit to demands vs. resistance/over-responsible vs. unwanted/sufficiency vs. feel deprived of care/approval vs. independence

She noted that, for such individuals, adulthood is often characterised by physical health issues, poor self-care, multiple stressors & chaos, major life events and emotional baggage.

She then provided some examples of cognitive distortions typical of such individuals, including:

§ “I’m not entitled to look after myself when there are things to be done for others”

§ “I can’t say ‘no’ to anybody…they may stop loving me”

§ “It’s better to be needed (and shattered) than feel well (and alone)”

§ “I have to cope regardless of how I feel/what I want”

§ “Some people admire the way I juggle so many balls at the same time!”

§ “Life’s too chaotic to stop and think about how to do things differently or deal with my past”

In such individuals, Meherzin noted that needs for care, love and approval/admiration are often unmet and strong emotions such as happiness and anger are often disavowed.

Meherzin went on to describe a psychological presentation typical of the patients with FM that she sees:

§ desperate, tearful

§ uncontained, messy

§ responsibility for change handed over

§ feeling out of control

§ feeling like a failure

§ terrified to improve vs. desperate to change

§ perception totally focussed on the body, pains, fatigue levels.

She described the following interpersonal behaviours as typical in patients with FM: stuck, clingy, demanding, overly grateful, apologetic and tearful, fearful of abandonment, referring to earlier strengths and handing over responsibility.

Conversely, Meherzin reported that the personal strengths of patients with FM include determination, resilience, a capacity for hard work, a commitment to sessions and a willingness to participate (if a safe environment is created).

Meherzin considered common reactions elicited in clinicians when treating individuals with FM including feeling stuck, feeling responsible, feeling trapped, feeling a sense of inertia, feeling frustrated, and feeling deskilled and helpless.

Meherzin suggested a management plan for individuals with FM that incorporated medical, physical therapy, psychological, social rehabilitation, occupational therapy and alternative remedy approaches.

Meherzin concluded her presentation by describing the main components of psychological treatment for patients with FM. These included managing pain, sleep, diet, dealing with difficult emotions and with the onset of trauma, helping the patient to develop adaptive coping strategies and increase assertiveness and unpacking and reframing historical and long term ‘baggage’.

A lively series of questions and discussion followed Meherzin’s presentat

Newsletter No 8 February 2005

PSYCHOLOGICAL TREATMENTS FOR MULTIPLE SCLEROSIS

      Professor Peter Thomas, Professor of Health Care Statistics & Epidemiology, IHCS, Bournemouth University and Dorset RDSU
      Dr Charles Hillier, Consultant Neurologist, Poole Hospital NHS Trust
      Dr Sarah Thomas, Senior Research Fellow, Dorset RDSU

The focus of this presentation was preliminary results from the Cochrane systematic review of psychological treatments for multiple sclerosis that is being undertaken by a collaborative team from the Dorset RDSU, Poole and Royal Bournemouth Hospitals and Bournemouth University. The protocol for the research has already been published in the Cochrane Library:

Thomas PW, Thomas S, Hillier C, Galvin K, Baker R, Cole J. Psychological interventions for multiple sclerosis. The Cochrane Database of Systematic Reviews 2003, Issue 4.

The presentation was given by three members of the team. Charles Hillier, Consultant Neurologist from Poole Hospital, provided some general background about multiple sclerosis - its aetiology, prevalence, pathogenesis, the diagnostic criteria that are used and the diagnostic process. He described the range of potential symptoms experienced and delineated different types of disease progression. He described the MS Service in East Dorset and the broad scope of services and organisations involved in the care of individuals with MS including medical and nursing professions, occupational therapists, physiotherapists, dietitians, speech therapists, clinical psychologists, counsellors, MS societies, disability advisory services, social services, mobility, continence, vocational and housing services and MS clinics.

Sarah Thomas, Senior Research Fellow from the Dorset RDSU, then considered psychological factors in multiple sclerosis. She noted that psychological factors are more prominent in MS than in other chronic illnesses with comparable levels of disability and suggested this may be partly due to:

the timing and complexity of diagnosis
the heterogeneity of disease course and symptom range and severity
the tremendous uncertainty that accompanies MS
concomitants of the disease process itself

She described how the wide range of symptoms in MS means that it can impact upon nearly every aspect of an individual’s life including self identity, interpersonal relationships, family functioning, sexual functioning, employment, social support, leisure pursuits.

She noted that depression is often considered to be the ‘hallmark’ affective symptom of MS and is possibly the most psychologically debilitating symptom. It is also the most extensively researched. Literature on other psychological factors is scant. However, there may be other psychological sequelae including anxiety, anger, guilt, low self-esteem, grief, denial, pathological laughing and crying, euphoria. Approximately 50% of people with MS will develop some degree of cognitive dysfunction.

Sarah used depression in MS as an example to illustrate the complex and multi-factorial interactions that can exist between psychological factors and disease-related factors and processes.

Peter Thomas, Professor of Health Care Statistics and Epidemiology from the Dorset RDSU started off with a brief overview of the history and structure of the Cochrane Library. He then outlined the stages involved in the review process from approval of the review title, preparation of the protocol, review of the protocol, publication of the protocol, undertaking the review itself, review of the review and finally the publication of the review.

He described important factors that need to be considered when designing and undertaking a Cochrane review including: the inclusion criteria, search strategy, method of data extraction, quality of studies, statistical analysis and the structure of the review.

He described the rationale for the ‘mini-review’ framework that has been adopted and summarised the 14 trials that have been found to date. He concluded his presentation with the following points

the most robust evidence is for CBT in depression
many studies are small (risk of type II errors)
multiple significance tests make interpretation difficult
reporting of trials was sometimes poor
the importance of choice of population
the diverse nature of outcome measures used
the need for further well designed trials

Psychological Aspects of Rheumatoid Arthritis
Dr Paul Thompson, Consultant Rheumatologist, Poole Hospital NHS Trust

The January meeting of the Mind & Body Network at Sandbanks Hotel featured Paul Thompson exploring the interaction between a ‘person’ and a chronic disease. In three groups participants discussed the personality features of the cartoon characters Popeye, Brutus and Olive Oyl, and speculated about the likely outcomes if the characters were to find themselves faced with the scenario of a fierce dog attacking Sweet Pea……. Brutus saved himself, Olive Oyl dithered and Popeye saved the day.

Moving from cartoon characters to the clinical setting Paul asked the three groups each to consider a hypothetical rheumatology case and to feed back to the whole group what they considered was happening to the patient and what treatment they would recommend. This exercise illustrated how certain individuals – so-called ‘robust types’ function far better with rheumatoid arthritis than others who have comparable objective disease activity but poorer coping strategies; indeed, robust types often appear to have worse disease in terms of joint damage and inflammation than the others.

In summing up Paul noted that while the biomedical model may be all that is needed to cure acute illnesses, a deeper understanding of the interaction between the soma and the psyche is essential for the wise management of people with chronic diseases.

The meeting was well attended with people enthusiastically participating in the group work. The meeting was kindly sponsored by an education grant from Pfizer.

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Newsletter No 7 October 2004

    Psychological approaches to IBS:
    Implications for psychological and medical treatment
             Dr Mary Reid, Senior Lecturer, IHCS, Bournemouth University

Irritable bowel syndrome has become one of the most prevalent diagnoses for cases presenting at gastroenterology outpatient clinics each week in the UK, affecting a significant proportion of the Western population. As a disorder, it can be chronic and significantly disabling for people who suffer from it. Frustrating for both doctors and patients is the relative lack of available approaches for treating it as a chronic disorder, although new, holistic approaches are being developed and evaluated. It is useful, however, to consider the factors that have made it difficult in the first place to conceptualise and treat this condition.

Until recently, diagnosing irritable bowel syndrome was unclear. Unlike inflammatory digestive disease, IBS could not be positively determined from a medical diagnostic procedure. In 1999, a shift from a disease- to symptom-based model of disorder was developed to describe functional GI disorders (Rome II, published in Gut, 1999), with the intention of incorporating a more holistic view of their genesis and treatment. Years of clinical study and observation were gathered from clinical practice and symptom clusters common and distinctive to each category were developed and involved international researchers and clinicians. These categories were based on the bodily location along with theoretical ideas about the nature of process underlying the symptom, and the qualities of the symptom cluster itself. Like the other disorders in this group, IBS is defined by symptoms, and their chronicity. They include abdominal discomfort or pain lasting at least 12 weeks, along with bloating, or other accompanying symptoms such as a change in frequency or appearance of stool, and relief upon defecation.

As far as the patient’s experience of illness is concerned, however, distinctions between disease and functional disorder may likely mean little. Irritable bowel syndrome in its more severe forms shares many symptoms with inflammatory bowel disease (e.g. Crohns disease, ulcerative colitis). Medications intended to soothe the irregular motility within the gut, or re-balance the chemistry of gut secretions and help aid digestive processes are for some patients, but may be limited in how much they help reduce symptoms, particularly over time. Many IBS sufferers agree that the impact of their symptoms tends to be underestimated. The impact of this disorder on personal functioning and psychological health can be disabling for some patients (Creed et al., 1999). This has been indicated in a number of studies reported a high incidence of co-morbid depressive, anxiety symptoms and interpersonal difficulties reported by patients (Talley et al., 1990). Although a number of self-help groups have been recently established to share information about helpful treatments and how to explore factors that increase their symptoms, it is still often difficult for IBS patients to learn about the potential causes of their symptoms and what they can do to manage them.

For a number of years, research has demonstrated a link between IBS and certain psychological characteristics or states. The idea that emotional arousal affects the gut is hardly a new one. Anyone can ‘feel gutted’ by shock or grief; or have butterflies or churning sensations in their stomach when feeling anxious or fearful. In addition, IBS patients have demonstrated a higher sensitivity to certain sensory stimulation in the gut (e.g. rectal distension), and lower thresholds to pain (Whitehead et al., 1997). More recent theoretical and empirical research have shown that this sensitivity may be caused by a lack of regulated activity between the gut and brain, which normally modulates responses to stimulation in the gut (Naliboff, Balice & Mayer, l998; Mayer, Chang & Lembo, 1998).

Other studies have shown a higher incidence of anxiety, depression, and sensitivity to novel, noxious or emotionally disturbing stimuli, or prevalent negative affect related to IBS (Lydiard & Falsetti, 1999; Eisendrath et al., 1986). Many IBS patients reveal a high frequency of negative thoughts about themselves or their expectations of others.

Of course, it is impossible to separate the cause from the impact in most of these studies, except in a few investigations where psychological symptoms have been shown to preceed GI symptoms (Whitehead et al., 1996). Certainly living with chronic gut disturbance might create some of the sensitivity, anxiety and other affective symptoms or syndromes mentioned (Drossman et al., 1999).

There is growing evidence that psychological approaches or integrative treatment can be useful in treatment. Interpersonal brief therapy has been shown to reduce gastrointestinal symptoms, improve quality of life for IBS patients (Creed et al., 2001; Guthrie, 1993). This treatment has also been shown to reduce the cost of NHS care for IBS patients. This kind of therapy attempts to help individuals learn about how they cope with interpersonal difficulties, as well as process emotional experiences more deeply. Cognitive –behavioural therapy has also demonstrated positive results, including a reduction in symptoms, and increase in self-rated health and quality of life (Green & Blanchard, 1994). CBT can be offered for individual or small groups of patients, and focuses on changing maladaptive illness perceptions or beliefs and altering coping strategies. Finally, relaxation therapy and hypnosis have been shown helpful in altering coping responses (Whorwell, Prior & Farager, 1984).

These different forms of therapy may help IBS patients in similar ways, however. Therapeutic intervention may help them develop links between events and certain kinds of conflicts people have with others, and within their own experiences, and help patients understand how their they handle difficult emotional responses such as anxiety or feelings of shame, incompetence, or fear (Read, 1999).

Although evidence is accumulating that psychotherapy and psychological treatments may be cost –effective and effective in reducing symptoms, psychological therapy or interventions as part of a multidisciplinary approach are still exceptional rather than routine. In addition, some patients may unnecessarily feel that being referred to psychotherapy or counselling does not mean their doctors believe their symptoms are all in their heads.

Finally, a number of studies examining quality of life and impacts of this condition have come to the conclusion that patients may well feel isolated when suffering their symptoms, and that others don’t understand what they go through (Sullivan et al., 2000). A patient’s health care team is not necessarily aware of her needs in relation to this illness, beyond symptom relief. There are several good reasons for this. First, it is reasonable to suspect that patients themselves may have difficulty in realising, and articulating all of their concerns related to illness and recovery, especially initially. They may worry that others do not believe their suffering, or disruption to their functioning, and therefore may feel their experience is invalidated by their illness, especially as it may not be amenable to traditional treatment.

Second, the relationship between psychological events and physical symptoms has often been difficult to track. It has been repeatedly demonstrated that trying to link stressful events and episodes of illness is difficult to achieve. Acute states of physiological disturbance have not always been associated with self-reported stress. Consider the situation where a person attempts to cope with their problems by distracting themselves from the sources of their anxiety, or by avoiding situations in which he begins to feel uncomfortable. By managing situations this way, he may remain unaware of low levels of anxiety that have been activated. It would be natural to feel that he was successfully coping, without being aware of the chronic impact this anxiety may have on internal processes (such as those occurring in the gut) over time.

Third, the same impact could occur when an individual typically inhibited her emotional responses or avoided difficult feelings needing further processing, and expression. Using certain defensive strategies that involve routine behavioural and physiological inhibition have been shown to cause disease and disorder (Weinberger, 1990), but individuals may be unaware of the link between these processes and stimuli that evoke them.

Findings like these, along with the correlational studies mentioned above, are usually given as evidence that some kind of chronic emotional distress may be linked to the maintenance of physically-based gut symptoms, at least in some patients. While there have been no investigations in which the kinds of conflicts experienced by IBS patients have been compared to other patient groups, other studies have indicated a range of chronic difficulties in interpersonal relationships, as well as the processing of traumatic experiences and emotions (such as vulnerability, humiliation and fear) related to them (Guthrie, 1993; Reid, in preparation). Helping patients become more aware of these conflicts or experiences needing personal understanding, or teach people how to increase their coping behavioural repetoire are becoming goals in psychosomatic medicine, and evidence is accumulating that approaches may be especially valuable for individuals with IBS. In addition, more sensitive approaches to uncovering patients’ concerns related to their illness, and assisting with their ability to manage their symptoms without isolating themselves from social, familial and occupational roles are also reasonable goals for recovery (Mitchell & Drossman, 1987).

References:

Creed, F.H., Guthrie, E., Thompson, D., Ratcliffe, J., Read, N., & Tomenson, B. (2001). Cost effectiveness of psychodynamic interpersonal therapy and antidepressants for chronic somatization. Presentation to the Society for Psychotherapy Research, (March: Leiden, Germany).

Creed, F.H., Olden K.W., Svedlund J., Toner, B.B., Whitehead, W.E. (1999). Psychosocial aspects of the functional gastrointestinal disorders. Gut,; 45 (Supp II):, II 25-30.

Drossman, D.A., Creed, F.H., Olden, K.W., Svedlund, J.,Toner, B.B., & Whitehead W.E. (1999). Psychosocial aspects of the functional gastrointestinal disorders. Gut,; 45 (Supp II): II 25-30.

Eisendrath, S.J., Way, LW., Ostroff, J.W., & Johanson, C.A. (1986). Identification of psychogenic abdominal pain. Psychosomatics,27, 705-712.

Greene, B., Blanchard, E.B. (1994). Cognitive therapy for irritable bowel syndrome. Journal of Consulting Clinical Psychology, 62, 576-582.

Guthrie, E. (1993). Psychological management of patients with irritable bowel syndrome. In M. Hodes & S. Moorey (eds.), Psychological treatment in disease and illness (pp. 88-100). London: Gaskell & the Society for Psychosomatic Research

Lydiard, R.B., & Falsetti, S.A. (1999). Experience with anxiety and depression treatment studies: implications for designing irritable bowel syndrome clinical trials. The American Journal of Medicine, 107, (SI) 41-50

Mayer, E.A., Chang, L., & Lembo, T. (1998). Brain-gut interactions: implications for newer therapy. European Journal of Surgery, ~~Supplement to vol.~~ 582 (S)50-5.

Mitchell, C.M., & Drossman, D.A. (1987). The irritable bowel syndrome: understanding and treating a biopsychosocial illness disorder. Annals of Behavioral Medicine, 9, 13-18.

Naliboff, B.D., Balice, G., & Mayer, E.A. (1998). Psychosocial moderators of quality of life in irritable bowel syndrome. European Journal of Surgery 583,(S) 57-9

Read, N. (1999). Harnessing the patient’s powers of recovery: the role of the psychotherapies in the irritable bowel syndrome. Balliere’s Clinical Gastroenterology, 13, 473-487.

Reid M. Psychological treatment of functional abdominal pain: outcomes revealed in process and therapeutic goals for the chronic care team. (in preparation for submission to Gut, 2004).

Talley, N.J., Phillips, S.F., Bruce, B., Twomey, C.K., Zinmeister, A.R., & Melton, L.J. (1990). Relation among personality and symptoms in nonulcer dyspepsia and the irritable bowel syndrome. Gastroenterology, 99, 327-333.

Weinberger, D.A. (1990). The construct validity of the repressive coping style. In J.L. Singer JL (Ed.), Repression and dissociation: Implications for personality theory, psychopathology, and health .(pp.337-386). Chicago: University of Chicago Press

Whitehead W.E., Crowell, M.D., Davidoff, A.L., Palsson, O.S., & Schuster, M.M. (1997). Pain from rectal distension in women with irritable bowel syndrome: relationship to sexual abuse. Digestive Diseases & Sciences, 42, 796-804.

Whitehead, W.E., Burnett, C.K., Cook, E.W., & Taub, E. (1996). Impact of irritable bowel syndrome on quality of life. Digestive Diseases & Sciences, 41, 2248-53.

Whorwell, P.J., Prior, A., & Faragher, E.B. (1984). Controlled trial of hypnotherapy in the treatment of severe refractory irritable bowel syndrome. Lancet, SII 1232 - 1234.

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Newsletter No 6 March 2004

Learning to attend to mind-body processes
Les Todres, Professor of Qualitative Research and Psychotherapy, Centre for Qualitative Research, IHCS, Bournemouth University.

Les' talk to the Mind-body Network provided an overview of a therapeutic approach that is being increasingly used to help patients process their sensations, thoughts and feelings. The approach is called Focusing and was developed by psychologist and philosopher Eugene Gendlin at the University of Chicago. Its practice has been relatively neglected in the U.K., and Les wished to raise awareness of the potential benefits of this approach and some of the research studies that had been done.

The talk began with some philosophical background about the difference between phenomenology and cartesian dualism. We have traditionally inherited 'packaged' terms such as emotions, cognitions, and bodily senses which tend to emphasise their separation. Focusing is based on a different philosophy that wishes to pay attention to a stream of experiencing that is complex and cannot easily be 'packaged' or defined. Here we enter the experience of a more 'fuzzy' area and this may be very relevant to understanding and dealing with mind-body interactions.

Initially, Gendlin was interested in researching the question of what is happening when people do well in psychotherapy. By focusing on the process issues involved, he and colleagues found that the difference was not to do with either the therapeutic approach taken, the content of what people talked about, or the diagnosis of the patient. Rather it had to do with the capacity of the patient to talk about their experiences in a particular way. He noticed that they paused and groped for words or images. On enquiry, they paid attention to an unclear but bodily-sensed aspect of how they were, a kind of moving back and forth between words and their bodily sense of their situation. Gendlin called this process Focusing, and found that it consistently differentiated between those that did well in psychotherapy and those that did not. A major implication of this for his therapeutic theory was that it centred on how people pay attention rather than a focus on the content of thoughts, feelings or sensations. His next question was to consider whether this process could be taught as a skill. The short answer to this was: yes, with some qualifications. A lot of research has been done since to clarify the learning and teaching of this skill to others and the benefits of such a process. Generally the process is more successful and has better outcomes when there is another person to help as a guide and companion.

The talk concluded with a consideration of some case studies that demonstrated the helpful application of focusing in health care settings. In one case it showed how focusing worked with a patient's experience of chronic physical pain in such a way as to change both the quality of the sensations and the meaning of the pain in helpful ways. Another study highlighted common themes between the focusing experiences of four HIV/Aids sufferers that led to greater experiences of felt vitality. Readers can find out more about Focusing philosophy, training and research at http://www.focusing.org.

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A Narrative Approach to Physical Disease
Dr Helen Smith, Professor of Primary Care, Brighton & Sussex Medical School

Helen Smith provided a fascinating insight into the potential therapeutic benefits of expressive writing.

Introduction

Writing has a profound influence on individuals and society. During the last twenty years there has been an explosion of interest in writing for therapeutic benefits. James Pennebaker pioneered a brief writing intervention in the late 1980s. His work has acted as a catalyst and has made expressive writing readily accessible as an intervention for use by health professionals working outside as well as within the mental health realm.

In personal accounts of his work, Pennebaker reveals that initially he was guided by intuition rather than by theory. He had been raised in a family in which there were considerable levels of ill health and little expression of emotion. He believed that encouraging the exploration of one’s deepest thoughts would lead to health benefits.

The Pennebaker Writing Paradigm

The standard Pennebaker paradigm involves getting an individual to write freely without interruption for approximately 20 minutes on 3 to 4 consecutive days about highly emotional topics. Its evolution as a brief intervention was largely due to pragmatic issues such as time and resource constraints.

Benefits ascribed to the Pennebaker paradigm include improvements in emotional well-being and in academic performance, reduction in self reported illness & physician visits and enhanced immunological well-being (enhanced T cell response, greater antibody control of latent viruses, enhanced response to vaccination).

It has been suggested that the primary mechanism through which the writing paradigm works is by initiating and facilitating the organisation of complex emotional experiences. This has been supported by evidence from research using textual analysis.

Much of the early research using this paradigm was undertaken using undergraduate students in laboratory settings. However, more recently it has been applied to patients in health care settings.

There are several characteristics that make this approach particularly appealing as a clinical intervention: it is inexpensive, it is portable, brief, requires relatively little operator skill, is readily deliverable in primary care, is safe and non pharmacological.

There is a now a substantial and growing body of literature applying Pennebaker’s intervention across a diverse range of mental and physical health problems including: breast cancer, post operative recovery, chronic pelvic pain, insomnia, rheumatoid arthritis, frequent attenders to primary care, caring for a child with autism and body image dissatisfaction.

Findings from research using the Pennebaker paradigm have been equivocal; for example, in the fields of breast cancer and rheumatoid arthritis some studies have reported patient benefits while others have not found such benefits.

Asthma pilot study

Helen and her research team wondered whether Pennebaker’s expressive writing paradigm could provide an adjunct to conventional pharmaceutical therapies and self- management plans for patients with asthma. They designed a community-based pilot randomised controlled trial that targeted adult asthmatics aged between 18-45 requiring regular inhaled medication (BTS steps 2-4) recruited via general practice. Those randomised to the expressive writing arm of the trial were given the following instructions:

‘For the next three days I would like you to write about your very deepest thoughts and feelings about an extremely important emotional issue that has affected you and your life. In your writing I’d like you to really let go and explore your very deepest emotions and thoughts. You might tie your topic to your relationship with others, including parents, lovers, friends, or relatives: to your past, your present or your future; or to who you have been, who you would like to be, or who you are now.

You may write about the same general issues or experiences on all days of writing or on different topics every day. All of your writing will be completely confidential. Don’t worry about spelling, sentence structure or grammar. The only rule is that once you begin writing continue to do so until your time is up’. (Adapted from Pennebaker & Beall, 1986 and Pennebaker et al., 1990)

Those randomised to the control arm had similar writing instructions except that they related to a bland topic (‘plans for the weekend’).

Lung function was used as an objective outcome measure. Secondary measures included quality of life and mood. Follow-up was undertaken at 1 and 3 months by postal questionnaires and a visit to the surgery for lung function tests.

The intention was to recruit 20 patients into the pilot. Five general practices agreed to participate and sent letters to their patients with asthma. Ten percent of patients responded and 10 patients were formally recruited. There was a high compliance rate once the patients had consented - all 10 undertook the writing exercise and completed the questionnaires and follow-up assessments.

The pilot study confirmed the feasibility of the study design but obviously did not have sufficient power to confirm or dispute effectiveness. Further development work will incorporate some qualitative elements to explore why we encountered resistance from GPs and the unexpectedly low response rate from patients.

Methodological Issues

There has been increasing discussion in the literature of methodological issues related to the Pennebaker paradigm. These include:

Does it make a difference whether the expressive writing is handwritten or typed?
Is there a ‘gold standard’ form of the intervention?
What is the most appropriate control condition (neutral writing condition? intensely positive writing condition? non-writing control group?)
For how long should participants be followed up?
Does the researcher/writing environment need to be standardised within studies?
Could the expressive writing be done verbally rather than in writing? (for example, the ‘Guided Disclosure Paradigm’ combines writing with verbal disclosure)

Learning to attend to mind-body processes Les Todres, Professor of Qualitative Research and Psychotherapy, Centre for Qualitative Research, IHCS, Bournemouth University.

A Narrative Approach to Physical Disease Dr Helen Smith, Professor of Primary Care, Brighton & Sussex Medical School

Helen Smith provided a fascinating insight into the potential therapeutic benefits of expressive writing.

Introduction

Methodological Issues

Learning to attend to mind-body processes
Les Todres, Professor of Qualitative Research and Psychotherapy, Centre for Qualitative Research, IHCS, Bournemouth University.

A Narrative Approach to Physical Disease
Dr Helen Smith, Professor of Primary Care, Brighton & Sussex Medical School