Interactive Journaling is an evidence-based approach to helping clients move through the stages of change. Two of its merits:
a) It’s an easy practice to implement. Materials and support are readily available online.
b) Clients seem to really like it. Interventions are more likely to stick when clients like them.
For lots more information on Interactive Journaling, here’s a Q&A with Steven Proctor, Ph.D., Principal at PRO Consultants and Assistant Professor of Psychology at Albizu University in Florida. He’s an addiction treatment services researcher and consultant well-versed in Interactive Journaling.
Can you tell me a little about your work and how you came to work in this area?
Let me just back up for a minute and say that far too often, substance use treatment program marketing strategies use words such as “preeminent,” “effective,” “proven,” “evidence-based,” etc. to describe their clinical services in the absence of objective empirical data to support such claims. I believe very strongly that individuals struggling with addiction and their loved ones deserve better than that. That is why I have chosen to focus my line of research on the evaluation of addictions assessment instruments, procedures, and perhaps most importantly, treatment outcomes. The ultimate goal of my work is to not only evaluate, but to hopefully improve both the efficacy and effectiveness of substance use treatment services.
You are an expert in the area of Interactive Journaling. Can you describe this intervention, what it looks like, and what it’s trying to accomplish?
In short, Interactive Journaling is an experiential and reflective writing process by which clients experiencing various mental health issues are guided and motivated toward positive life change. I’d also like to note it is included in the National Registry of Evidence-based Programs and Practices (NREPP), a searchable online database of empirically-supported mental health and substance use interventions.
To provide a bit more background and detail, Interactive Journaling encompasses elements from the Transtheoretical Model of Change (TMC) and Motivational Enhancement Therapy (MET). The TMC views behavior change as a process involving several stages beginning with precontemplation and progressing thorough contemplation, preparation, action, maintenance, and finally termination. MET is a directive, non-confrontational, therapeutic approach whereby clients are led through the process of assessing their current situation and determining what strategies might be employed to assist them in identifying and achieving behavior change. Motivational Interviewing, a component of MET, is a style of communication that operates on the premise that clients are best suited to achieve change when motivation comes from within themselves, rather than being imposed by the clinician.
Interactive Journaling builds on this foundation through guided questioning strategies and graphic-enhanced text designed to aid clients in examining the emotions and thoughts surrounding maladaptive behaviors via Interactive Journaling booklets. An MET approach appears quite appropriate for clients with a drug or alcohol use disorder, and may facilitate their progression through the various stages of change included in the TMC. In accord with MET, the main objectives of Interactive Journaling are to build self-efficacy and elicit “change talk” with the overarching goal of resolving ambivalence regarding changing a particular problem behavior such as excessive substance use.
If I tell my patients to keep a journal while they’re in rehab, is that Interactive Journaling?
Not quite. Simply keeping a personal journal while in treatment—although of potential value and unlikely to cause any undue harm—is not Interactive Journaling. Interactive Journaling is a trademarked process that differs from traditional journaling in that it is structured and guides clients through the difficult process of making a positive life change.
Don’t get me wrong: journaling in general or “expressive writing” has long been shown to be a valuable component of many effective learning strategies and can have beneficial psychological and physical health effects, but writing in a personal journal does not constitute Interactive Journaling.
Are there different types of Interactive Journals?
Yes, there are actually dozens of specific Interactive Journals authored by a number of recognized experts in their fields. Some journals deal exclusively with addictions, others focus on additional mental health issues such as trauma, and there are also journals that may be appropriate for clients experiencing problems in both areas (i.e., co-occurring disorders).
Certain journals are intended for use with adults, while others are designed explicitly for adolescents. Interactive Journaling can be used in community mental health treatment settings across multiple levels of care (e.g., standard outpatient, intensive-outpatient, residential), as well as with criminal justice involved populations (e.g., county jail inmates, state or federal prison inmates, DUI offenders, parolees). There are also journals designed specifically for select populations at elevated risk for the development of mental health and/or substance use issues, including college student drinkers and veterans transitioning to civilian life. Given the range of mental health conditions covered and diversity of treatment settings in which journaling can be implemented, Interactive Journaling may actually be better conceptualized as the delivery vehicle for the core information and content of most value to your clients.
I think it’s also of interest to mention a few of the authors of various Interactive Journals, which include: William R. Miller, Ph.D., one of the fathers of Motivational Interviewing; G. Alan Marlatt, Ph.D., a true pioneer in the field of addictive behaviors due to his many clinical and research contributions in the areas of Relapse Prevention and Harm Reduction; and David Mee-Lee, M.D., the chief editor of the American Society of Addiction Medicine’s (ASAM) first, second, and third editions of The ASAM Criteria.
What does the research tell us about Interactive Journaling for people with substance use disorders?
Preliminary findings from experimental and quasi-experimental evaluations support a link between Interactive Journaling and behavior change among a variety of populations, including most notably individuals with substance use disorders.
Our first randomized controlled trial, published in 2012, investigated the effectiveness of Interactive Journaling in reducing criminal recidivism among substance-dependent county jail inmates. All 183 study participants: 1) met DSM-IV criteria for substance dependence, 2) were under the influence of a substance at the time of offense or committed the offense to obtain or get money for substances, and 3) had a minimum of one previous arrest in the 12 months prior to incarceration. Inmates were randomized and subsequently allocated to either an Interactive Journaling condition or a control group in which they received a federal brochure on substance use disorders and offending as a placebo.
Results revealed that inmates who received Interactive Journaling had a significantly lower criminal recidivism rate during the 12-month period following their release from jail compared to inmates assigned to the control group (51% vs. 66%, respectively). Thus, our initial research findings suggest that Interactive Journaling appears to show promise as a brief intervention strategy for substance-dependent county jail inmates and may have the potential for reducing criminal recidivism.
Does a person have to have a diagnosable SUD to benefit from Interactive Journaling?
Not necessarily. Although some of the research support dealing with Interactive Journaling comes from samples comprised of individuals with a documented substance use disorder, there are journals available for subclinical populations who may not have a formal diagnosis but are still experiencing impairment as a result of their substance use.
For example, one journal designed specifically for college student drinkers, titled CHOICES About Alcohol: A Brief Alcohol Abuse Prevention Program, may be used for all three levels of problematic alcohol use prevention for college students (i.e., indicated, universal, and selective). That is, the journal may be used in the context of an indicated prevention program for college students who have already developed alcohol-related problems (e.g., mandated college student drinkers in violation of university policies on alcohol use), a universal prevention program directed at the entire campus community, or a selective prevention program targeted at specific high-risk subgroups of students (e.g., freshmen, intercollegiate athletes, members of the Greek community).
However, the question of whether sub-diagnostic individuals evincing symptoms of a substance use disorder–but not quite meeting the diagnostic threshold–can benefit from Interactive Journaling is an empirical question that warrants further research.
Do you have clinical experience with Interactive Journaling? Can you share some impressions or anecdotes about its benefits?
Although we have talked a lot about my role as a researcher in the study of Interactive Journaling, I also have quite a bit of experience with the clinical side of things and have delivered Interactive Journaling to over 100 individuals. Populations I have worked with include substance-dependent inmates and high-risk college student drinkers mandated to participate in a brief intervention due to violation of campus polices on alcohol use.
I think what I have found most striking about Interactive Journaling is how many times participants have commented on how much they appreciated having a tangible resource they could use for future reference. I find this interesting because the prerequisite for Interactive Journaling, or any approach designed to facilitate behavior change, is that the intervention be favorably received by the population whose behavior is to be altered. In other words, an important consideration in determining the potential effectiveness of a particular intervention for a particular group is to explore the extent to which they are willing to use it, as well as their level of satisfaction with the intervention.
Based on my prior research and clinical experiences with Interactive Journaling, it appears to be extremely well-received.
Based on my prior research and clinical experiences with Interactive Journaling, it appears to be extremely well-received. For instance, of the 100 county jail inmates offered the specific Interactive Journal used in our first study, all but two agreed to take the journal—an acceptance rate of 98%. With respect to the mandated college student drinkers, the general consensus was that the Interactive Journaling program was both understandable and helpful, and they intended to not only keep the Interactive Journal, but recommend the program to others following completion of the program.
If I were a clinician or an administrator interested in implementing this intervention, how could I find more information? And is there guidance for how to best implement it?
The Change Companies’ website includes a wealth of information on the numerous journals and training resources offered regarding the delivery of Interactive Journaling with options for live training, electronic training, and video training. Each journal also comes with a detailed facilitator guide, which offers suggestions to help service providers structure programs according to their unique needs, comments/notes highlighting key topics corresponding with each journal page, and supplemental activities clinicians may consider assigning their clients as homework to reinforce content and encourage practice.
Additional information is also available through the NREPP database. Of particular interest, NREPP provides a Readiness for Dissemination rating for all included interventions, which is an indicator of the amount and general quality of the resources available to support the use of the intervention. The Readiness for Dissemination rating applies to the intervention as a whole, and is based on a scale ranging from 0.0 to 4.0. The three criteria used for evaluating the intervention’s Readiness for Dissemination include the availability of implementation materials, training and support resources, and quality assurance procedures. The Readiness for Dissemination rating for Interactive Journaling is a 4.0—the highest possible rating an intervention can receive.
Are you looking forward to any particular work in this area in 2016?
Right now, I am working to establish a research partnership with an addictions treatment center to serve as the site for a randomized clinical trial evaluating various Interactive Journaling curricula (i.e., both cognitive-behavioral and 12-Step focused journals) on a number of relevant outcomes such as engagement in continuing care plans following completion of primary residential treatment care.
Despite generally positive preliminary research support for Interactive Journaling, and its high NREPP Readiness for Dissemination rating (i.e., 4.0 on a 4.0 scale), we need further research to evaluate the impact of specific Interactive Journals among additional high-risk populations. I am mapping out future research efforts to evaluate the potential mediators and moderators of effectiveness for Interactive Journaling, and separate the effects of its various components, in order to improve substance use treatment outcomes.
