How to Use Structured Writing to Help Clients Unclutter

How to Use Structured Writing to Help Clients Unclutter

by Pamela Garber
Using a structured, written, organizational map can help clients disentangle their many problems, so they may begin effectively addressing them in therapy.


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Mary was like a game show contestant, reaching for the top prize that came with climbing to the top of her list of priorities
The clock struck three and Mary was calling me on Zoom. Before I could say “Hi,” she was reading from a crumpled paper held in clenched fists. This was her weekly list of the topics that she wanted to bring to therapy. Her timing gained momentum until her words reached a breakneck pace. It seemed that I was witnessing a contest. Mary was like a game show contestant, reaching for the top prize that came with climbing to the top of her list of priorities.

Mary: The Gravitational Pull of Lifelong Habits

I waited until Mary finished reading, and then after taking a few deep breaths, began the arduous task of adding some modicum of structure to her list — rating the topics, determining their priority, and then talking out the prioritized topics in a bit more detail than she originally planned. Mary dutifully and enthusiastically jotted down notes corresponding to the topic at hand.

While rapport came easy with Mary and our conversations typically flowed, a seemingly interminable pause — you know, those that are unique to online therapy — Mary proclaimed, “I know, I know. I’m not ready to give up being the rescuer.”

“You think?!”

Before continuing, she gave me her usual comedic smirk and said, “But this is all real. I have a vitamin company that I’m running solo because…Um, well. It just happened. Sort of. Slowly.”

Knowing the answer, I asked in jest if Mary was still office manager at the commercial real estate company where she began working 15 years ago. Mary nodded. We turned back to her list. There were a few items that Mary also described as having “just happened.” These included volunteering to cook Thanksgiving dinner for her husband’s family and letting her sister-in-law stay with them for a long visit with an end date that was “to be determined.”  

Mary regarded her anger as a simple and logical reaction to her daughter’s forgetfulness
Prior to that session, Mary had been angry that her daughter had forgotten to place an order for groceries, making it necessary for Mary to stop and bring home dinner for the family on a very cold night after leaving the office. Initially, Mary regarded her anger as a simple and logical reaction to her daughter’s forgetfulness, but because there was already a template in place from an earlier clustering of items on her list, she finally seemed ready to identify another significant pattern of behavior she very much wanted to address, and hopefully change.

“My mother was always angry. She was the Lone Ranger, always putting out fires that we all set. My siblings and father, that is; not me! I did what I was supposed to. At some point, I became everyone’s helper. I guess I learned to do this when my mother became depressed.”

We eventually got to a point in Mary’s processing where she saw that there was a historical satisfaction she received from maintaining order by handling everything around her, instead of accepting the risks that came with engaging, or directly asking for the help of others. When others failed, as they invariably did, Mary felt anger. It wasn’t anger; however, at the perpetrator, but at herself because of her intractable belief that she had to then pick up the slack and failed to do so — and instead, outsourced. This rescue theme permeated all facets of her life.

Mary was circling items on her list that felt optional when she put her face in her hands. After some minimal silence, Mary described how she felt the first time she noticed her mother’s depression. “The sadder she looked, the busier I became. The busier I became, the less my brothers and father were doing. No chores or help around the house in any way.”

Through writing lists and seeing reality in print, right in front of her, Mary was able to appreciate the wide scope of her expectations of herself, and her role in continuing to be the rescuer to prevent the potential for disappointment from others.

Terry: Therapeutic Lessons in Self-Advocacy through Writing

Terry, aged 35, presented in a very warm wool blazer over a buttoned-up Oxford shirt that looked uncomfortable. His mannerisms seemed almost choregraphed corporate professional in such a way that made me think that he was working too hard at appearing polished. I believed that still waters ran deep with Terry, but I delayed my full impressions.

his mannerisms seemed almost choregraphed corporate professional in such a way that made me think that he was working too hard at appearing polished
“I just can’t take my life anymore! Oh, no, not like that. I mean, I’m fine. Well, no, thanks to them, I am not fine. Or thanks to me, maybe. I could just leave, but then they need me, and I’m committed to seeing these changes through. I made a commitment. And I need the money. This is a huge opportunity. And, at the same time, this is no way to run a company and no way to treat a human being.”

Terry paused, looking at me almost apologetically. Wanting to normalize his expressive shouting, I nodded as if we were already in a working alliance and immediately went into establishing the presenting problem, before moving carefully into recent history. Terry’s upbringing seemed complex, and his expanded HR role at work which included dispute resolutions and public relations, seemed to mirror those early-life experiences.  

in describing his days, Terry painted a picture that felt very much like a Pollock painting
In describing his days, Terry painted a picture that felt very much like a Pollock painting — taking meetings, picking up prescriptions for his uncle, being too tired to enjoy a weekend party, listening to a manipulative employee with a treacherous track record fabricate a story about discrimination, and finally, feeling financially burdened, depressed, alone, and coping with “a heart that feels like it’s doing summersaults inside my chest.”

As he frenetically laid out the complex intertwining of work and family-of-origin demands, once again, I had trouble catching my breath. Like a sports referee, I motioned for time-out, nodding slightly to offer Terry assurance that I wanted to understand everything, and to do so, I needed separation and space between each different subject. Granted, that’s not the effect that Pollock was aiming for, nor would we want to break down and bring order to his works, as chaos seemed to be the goal. But I explained to Terry that while the head-spinning menagerie of topics he was tossing onto the canvas of our session gave us a lot to work with, it would otherwise be helpful if we could indeed structure his topics and disassemble the inner chaos.

I’ve found that one of the many ironies in therapy is that the more issues are linked together, the more important it is to first separate them out. I’ve had good clinical luck by establishing traction with one issue at a time, usually the most current “hot topic.” The high voltage of that topic usually complicates and obscures other issues, regardless of when they arose in the client’s life. Without separating, wires cross, and I have frequently sat in an electrical storm of past and current issues as they collided in a dazzling and confusing Pollock-ian explosion.

Terry’s past did clearly contain some currency. He described being alone most of the time as a child, until his parents rented their basement apartment to his aunt and uncle. His uncle became his mentor. Terry emulated his uncle and grew up having two role models — his father and his uncle. Terry empathically described the contrast between his parents’ old fashioned work ethic of long hours and constant worry about the business, and his uncle’s more creative and impulsive risk taking. His uncle had a wild ride of achieving financial success after living for a time in the basement apartment, moving out and buying an enormous house on a fancy street in Brooklyn, only to lose everything 10 years later and wind up back in the basement, divorced, and working for Terry’s brother.   

Terry’s formative years were spent being caught in a tug-of-war between his father and his uncle
Terry’s formative years were spent being caught in a tug-of-war between his father and his uncle. His father wanted to hand the restaurant over to his son and his uncle wanted Terry to go to college. Terry did both, but through the years, he became the go-between for the two men. Unconsciously, he feared rejection from his father and carried this with a constant state of nervous energy and anxiety attacks, somatic digestive symptoms, and an obsessive monitoring of his health. His present work environment had some shared features of his family of origin homelife and ongoing sense of family-based obligations.

Terry was getting visibly angry within three minutes of our second session. He wanted to alleviate the sting from his recent reprimand at work, yet at the same time, he knew that he was in the right, and that his supervisor’s issues of paperwork falling through the cracks was 90 percent due to lack of administrative support and maybe 10 percent human error. Terry needed to fight back with professional decorum, but first, he needed to calm down. My suggestion was to disentangle the different items and then respond to each one — to himself — on paper, as preparation for communicating with his supervisor.  

eventually, through his writing, Terry became fully prepared to meet with his supervisor
At first, Terry was irked, reluctantly pulling his laptop open and making a few nominal clicks. As we talked and Terry clicked, we created separate headings for each action item that was part of his entire merging of multiple job receptibilities. This master list with heading included multiple separate jobs that he had been unofficially asked to cover, without any new prospects for hire. Terry was pleased, and I was proud of him. As he gained clarity in the organization of his responsibilities, he also increased his personal conviction — his inner authority. Eventually, through his writing, Terry became fully prepared to meet with his supervisor. The meeting was without the previous subject of Terry being a remedial employee and failing to live up to expectations. Rather, this meeting was direct, goal-oriented, and successful.

The Positive Impact of Therapeutic Writing

In my experience with clients like Mary and Terry, I’ve found that when a client states facts on paper, they are also asserting the following:

1. They have the authority to interpret and define the facts
2. This authority is not subject to permission or approval from another
3. They have custody over the facts, as they are
4. They have the right to communicate these facts to another person, and doing so is not a betrayal or violation

Writing as a means of expressing feelings is well known, but the use of technical, terse writing can also be a valuable therapeutic tool. The tracking done in REBT and CBT therapy fits with clients when they are at a point of delving into activating events, beliefs, and consequences, but so often they also want to fully describe all the different scenarios they live out week to week. They want to take their therapist through a deep dive into the details of what transpired. This can often result in a confusion of ideas, goals, and plans, much like Mary and Terry initially experienced.

Technical writing can also be an effective means of helping a client work through the struggles of day-to-day life, including communication with others. Writing between sessions gives a client the opportunity for greater insight while deciding in advance of session time what is important to focus on. Sometimes, clients uncover a theme for the week as a direct result of writing. Whether a laundry list format or paragraphs, writing can fit easily within sessions on an impromptu basis. While the undesired feelings (dissatisfaction, grief or anger, or irritating tasks such as administrative responsibilities) do not get resolved through pen to paper or typing in a device, there is clarity through organization. This is similar to how balancing books doesn't make the red go to black, but often results in a feeling of ease.

Getting Organized: The Pre-Therapy Phase

After getting a baseline history and general understanding of the client’s concerns, there is a pre-therapy phase, akin to treatment planning. This phase begins by sifting through past and present to hit on the main problem of this moment. What is being experienced now that is problematic? Why is this problematic? What are the consequences? Is any of this problem optional? Could there be any benefits — even the kind of benefits that have more consequences later, such as avoidance? At about this point, I ask my clients to write down the words “Secondary Gains.” Some immediately Google it and some tell me the definition, as if on cue.

Once the main problem is identified, then the work of uncovering the various aspects within the problem becomes the next step. Technical writing is an ideal tool for this phase and can be a useful complement for therapy throughout the process.

The Top Card

My clients are accustomed to me saying that there is only one card at the top of each deck. Before selecting the top problem, it often helps to sort out problems into two basic categories.

In therapy, a problem is not always a separate entity, such as struggling with a recent promotion at work or difficulty adjusting to a new city. Rather, problems are sometimes complex and long standing, such as pervasive anxiety or depression or life patterns stemming from a background of trauma.

Often this pattern results in multiple struggles, where each struggle may seem like an independent problem, but each problem is part of a cluster of circumstances spurred on by the damaging pattern. In session, we take a sheet of paper and draw a line down the center. At the top of the page, we write a title on each side. On the left side is Problem Group A — Discrete Problems, and on the right side is Problem Group B — Overarching Patterns.

Problem Group A, for example, may be difficulty accepting a recent job loss, and Problem Group B typically shows up as a cluster of events or consequences linked to a combination of undesired habits, such as isolation, anxiety, and an endless state of resentment.

Problems from either category require teasing out and separating the different aspects. Aspects often include finding meaning in the problem and uncovering the types of environments and circumstances when the problem feels more present. There is often overlap between the discrete situation problems and the overarching pattern problems. But, even with this overlap, there is ultimately one card at the top of the deck and one situation or state of mind to home in on before delving into the others.

While this strategy may seem formulaic and concrete, I have found it very useful for clients like Mary and Terry, as they have tried, and successfully disentangled, prioritized, and addressed the problems that have plagued them. Doing so has also helped me to breathe a bit easier with clients who might otherwise pull me in the Pollock-like paintings of their lives. 

Pamela Garber Pamela Garber, LMHC earned her Masters degree from Nova Southeastern University and her undergraduate degree from the University of Texas. In addition, she studied film production at the Film Lab Actor’s Lab in Las Colinas, Texas. Combining psychology and film, she developed and produced a behavior modification program called Playing the Tape, a DVD curriculum series with a workbook and assessment. Her website is