Introduction {#sec1-1}
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One that is developed to support psychotherapy in limited time is expressive writing. Expressive writing (EW) has many names and variations with basic principles that are almost similar; including narrative therapy, autobiographical writing, experimental autobiography, life-review therapy, written exposure therapy, etc. The basic principle of this therapy is reflective, non-judgmental, and supporting self-construction change within treatment \[[@ref1]\].

EW was initially developed for students with physical symptoms who experienced traumatic sexual experience before age 17. They regularly wrote about their trauma for four days, 15 minutes a day. In the following six months, the number of visits to student health services was reduced by about half compared to the control group \[[@ref2]\].

In subsequent developments, EW can be part of cognitive behavioural therapy (CBT) or other types of psychotherapy \[[@ref3]\]. EW can also facilitate catharsis "such in a safe and private place", especially for the trauma that cannot be revealed to other people, even therapists. When patients share the writing in the therapy room, EW can be a bridge to self-projection as an initial step towards self-acceptance \[[@ref4]\]. On the one hand, whether EW is part of psychotherapy or not, it is enough to help the independence of the patient so that it does not depend entirely on the therapist \[[@ref5]\].

Methods {#sec1-2}
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This study consisted of two steps; there were; (1) the EW concept is derived from the work of James W. Pennebaker \[[@ref2]\], then some relevant literature is collected for cultural adaptation in practice for Indonesian as brief psychotherapy in an outpatient setting. This adaptation must be able to show the flow of therapy so that it could be easily followed by the therapist and the patient in each stage, make it easier for both to plan the therapy agenda, and also prepare for therapy termination; (2) selecting patients who were considered to represent a diagnosis of psychotic and non-psychotic, with certain cognitive adequacy that can follow all therapy sessions within some period of time. Each patient was still having medication-as-usual with expressive writing used as an adjunctive therapy.

Results {#sec1-3}
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Case studies {#sec2-1}
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The three cases that used in this paper were: (1) A 29 years-old male, worked as a system analyst in an IT company, secretly admitted as same-sex attracted since 14 years-old. He suffered from panic disorder since last year, had depressed symptoms and suicidal thought since he assumed that same-sex attraction symptoms disrupted his friendship in the office and made him frequently trapped in ambiguous situations between men and women; (2) A 38 years-old female, an elementary school teacher, suffered from depression and had suicidal thought, since his husband cheated four years ago. Since childhood, she was never taken care by her parents but by their siblings, had history of physical and emotional abuse from her caregiver which she kept secret from other people even her parents; (3) A 65 years-old female, a housewife, suffered from paranoid schizophrenia with persistent auditory hallucination since two years ago, had recurrent behavior to stab her husband due to her hallucination, experiencing hearing impairment since five years ago without any signs of cognitive decline. All patients were informed before and signed informed consent to undergo EW as part of their treatment.

Literature research {#sec2-2}
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EW has proven useful in a variety of physical and psychological causes, such as chronic pain \[[@ref5]\], irritable bowel syndrome, reducing blood pressure levels, reducing rumination in anxiety and depression \[[@ref6]\], and improving work performance including school-age children and employees \[[@ref7]\]. EW is easily applied in primary services because it is time and cost-effective and does not require strict structures such as CBT \[[@ref6]\]. EW can also be applied to non-formal and non-hospital psychiatric services such as in community activities \[[@ref1]\].

Like other psychotherapy models, EW still requires patient approval to follow the program until the end, and the patient can stop at any time if it is felt to be useless or dangerous for him/her. One thing that should be considered when doing EW is increasing negative effect when writing \[[@ref8]\], although, in the end, EW gives better results than the control group. This increase in negative effect is related to the trauma explorations carried out by the patient. After 24 hours, this negative effect decreases significantly; even patients reach a more calm state than before writing \[[@ref9]\]. At the meeting session, the therapist needs to supervise the possibility of re-experiencing the trauma in patients closely.

Two critical factors that support the success of EW are the patient's ability to release his trauma \[[@ref10]\] and find new meaning through what he has written \[[@ref11]\]. Releasing trauma includes readiness to write a traumatic experience in the form of words, reflecting events after events and willingness to label each emotion in each event. Discovering new meanings includes trying to look at events from different perspectives and plan hopeful actions for the future.

To support these two abilities, the therapist does not provide specific targets to the patient and frees the patient to write down what they deem unpleasant. A target-free EW tends to be more stress less and enriches the patient with a new perspective. It will focus on cognitive reprocessing on the dynamics they have experienced \[[@ref9]\]. Even if it provides a target in EW, the therapist should adjust to the main issue of the patient at the time \[[@ref8]\], while freeing the patient to write down other necessary things.

Adapting formula into practice {#sec2-3}
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EW was carried out with narrative-counselling (NC) \[[@ref1]\] and meaning-making (MM) \[[@ref11]\]. EW was given in the form of homework, while NC and MM were carried out in the therapy room. A cycle diagram for EW was used in this paper ([Fig. 1](#F1){ref-type="fig"}).

When performing EW, the patient was asked to write down in detail the traumatic events, including any sensory sensations, inner experiences, and all subjective viewpoints about the event. This written memory was carried out then by a cognitive process through NC \[[@ref12]\], to reorganise or restructure what was thought and felt about the event \[[@ref7]\], \[[@ref12]\]. In the end, the patient was guided to find new meaning derived from his writing.

When doing MM, patients could find new insights into events that might be forgotten, or any other possibilities that had risen and worth writing on the next EW. When a patient succeeded in finding new meaning and was able to do future planning on the topic they chose, then the patient did not have to continue with EW and could switch to other types of therapy. However, patients were still able to continue writing if deemed necessary.

![The flow of expressive writing consisted of expressive writing itself, narrative counselling, and meaning-making](OAMJMS-7-2602-g001){#F1}

Monitoring was carried out on all cases, including symptoms improvement that was subjectively felt by patients compared to his/her desirable targets, length of time and number of sessions, as well as possible side effects such as re-experiencing traumas. During therapy, patients were still advised to continue with medication as indicated.

Findings {#sec2-4}
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From three cases, there are significant outcomes in all cases but also considered a serious adverse event in case one and case two. Some findings related to symptoms improvement and possible side effects, compared to desirable targets, length of time and number of sessions, are summarised in [Table 1](#T1){ref-type="table"}.

###### 

Summary of findings

  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  Case    Sessions                                                               Desirable target               Symptoms finding & improvement                                                                                                                               Possible adverse effects
  ------- ---------------------------------------------------------------------- ------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------
  One     32 (eight months, once per week, 15-20 minutes per session)            Changing sex orientation       \- "Father hunger" which is realised since 10 years-old, is decreasing, 'unfit' sex orientation then perceived as 'unfit' bodily sensation.\                 \- Obsessed with the desire to change sexual orientation, masturbation to female fantasy as a form of compulsion to relieve the fear of "being gay".\
                                                                                                                - Fantasy with masculine men is diminishing, begins to be attracted to the opposite sex.\                                                                    - The obsession mixed with low self-esteem leads to attitude towards women aggressively.
                                                                                                                - Wet dreams are still with men, still attracted to inferior men, afraid of "being gay" that lead to obsession.                                              

  Two     18 (six months, once-twice per two weeks, 15-20 minutes per session)   Cope with husband's cheating   \- Increasing self-esteem towards her husband, assertively speak.\                                                                                           \- Aggressiveness towards her child, as displacement from her husband.
                                                                                                                - Experiencing amnesia-like or dream-like state after writing. Double identity symptoms arise, but ego started to integrate when reflecting with writings.   

  Three   10 (seven months, once-twice per month, 10-15 minutes per session)     Cope with hallucination        \- Hallucination frequently decreasing, able to distract.\                                                                                                   \- Decided not to continue EW, feel that improvements become stagnant, a possible cause of mental fatigue.
                                                                                                                - Insight to her symptoms, increasing medication adherence.                                                                                                  
  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Discussion {#sec1-4}
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Therapy dynamics {#sec2-5}
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The challenges of psychotherapy when working with patients with gender dysphoria (such as the first patient) is the inconvenience with their existing gender. Any attempts to change the sex orientation did not reassure them. This "binary gender bias" (man-woman) can trap patients and therapists so that the psychotherapy process will find a dead end. In the first patient, this binary gender bias is indicated by the presence of obsessive symptoms in which he refuses to return to being gay. Instead of confronting their existing gender bias, therapists should try to help patients explore things that make them inconvenience with their existing gender \[[@ref13]\]. This patient found that his inconvenience with the existing gender was due to a lack of father figure who had died since the age of 10 ("father hunger"). When the therapist worked on this issue, and the patient is quite open to his condition, the patient's perception of sex orientation gradually changes. Non-target EW makes it easy for patients and therapists to be flexible about the evolving therapeutic dynamics. Even though he still experienced same-sex wet dreams, his fantasies about men had gradually diminished, and interest in the opposite sex began to emerge.

The second patient showed a fairly wide imbalance between the results achieved with the adverse events. Patients felt more confident to talk to their husbands, but the amnesia-like condition is triggered and makes her appear suspiciously double identity disorder-like symptoms. This might be a severe adverse event and caused the appearance of new symptoms that lead to a different diagnosis than before. On the other hand, EW can explore things or symptoms that may have been hidden in the usual counselling process. By freeing patients to explore themselves through EW, patients can determine how deep they are to explore their psychodynamics independently without therapist intervention. Although in the end, the patient experiences an ego integration process (which also occurs through the writing process), by observing the symptoms in this second patient, the therapist should be aware that the negative arousal as mentioned earlier can be so severe.

One of the recommendations for therapists is to do emotional processing through a face-to-face session with patients. Emotional processing is carried out in the NC session, which begins with identifying the patient's global stress, then labelling the emotions that emerge. This emotional labelling helps patients actively realise and make it richer in the experience without having to re-experience the trauma. The therapist needs to introduce the existence of emotional reactions that may arise and invite patients to be proactive in realising the emergence of these emotional reactions. This directive process may only be done in the therapy room (while EW is done outside the therapy room), but is said to be able to support the achievement of results that are more satisfying for patients \[[@ref8]\]. This directive process allows patients to be actively involved in the process to be carried out through EW, not just passively so that it re-ignites the psychological trauma that has occurred. The therapist can ask patients to label themselves independently of these emotions so that negative arousal can be anticipated from the beginning before the patient performs EW independently.

Managing adverse events {#sec2-6}
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The therapist needs to be aware of possible adverse events, as seen in the first and second patients. The therapist's initial knowledge of the patients' dynamics determines how aware the therapist is of the negative effect that was previously predicted. In addition to explaining it as information for consent before, therapists need to educate patients during the session about the possibility of the emergence of this negative effect and what patients can do to anticipate it. In the first and second patients, the one that keeps the negative effect of being impacted clinically is by constantly asking patients to be disciplined about their medication.

Another way to anticipate this adverse event, the therapist should choose carefully to change topic or focus between session. Therapists have alternatively used NC so that patients can have a place to express complaints that relate to their adverse effects, and help them find new meaning through MM. If the adverse effect is felt to be burdensome, the therapist can offer the patient to make an additional agenda related to the adverse events.

Patient selection is one of the important factors in EW. Cases with suspected comorbid personality problems (first and second patient) had many therapy sessions compared to the third patient. One of the risks of a shortened session time in the psychiatrist's practice is the possibility of an increasing number of sessions in the future. Comparing to the first and third patient, the number of sessions increases the risk of lost cases because the patient was tired and getting obsessed if he felt that there was no progress in the treatment process. However, EW has been proven to help patients achieve their desired target while still having other adverse effects during therapy. Pennebaker himself mentions through the theory of inhibition, that low and long-term exposure such as EW, is healthier and has a better impact on body immunity, than high and short-term exposure as revealing trauma during counselling or psychotherapy \[[@ref2]\].

It is also a challenge for a psychiatrist to overcome his/her mental fatigue for a significant number of sessions. Although the duration of each session is quite short, if the psychiatrist is not sufficiently aware of the slightest progress of the patient, then he/she is also at risk of feeling hopeless and will not be able to encourage patients to continue therapy. It is essential for psychiatrists who will use EW, to appreciate the slightest progress of the patient, so that the patient still feels that this therapy is useful for him. Psychiatrists also need to work with family or community, to empower patients as their needs of writing, so that patients can perform independently at home or community.

Limitations {#sec2-7}
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This paper tries to find out the possibility of doing psychotherapy in limited time without violating the rights to get the best therapy. The new paradigm in psychotherapy is to achieve their independent life, as part of quality rights; the psychiatrist's adaptation in the term of psychotherapy is expected. By bringing together the goals of therapy (reaching independent living) with the best techniques that patients can do independently (such as writing as homework on CBT), then EW is formulated so that it can be applied to patients, especially in Indonesia. The existence of cultural barriers such as the unfamiliarity of Indonesian patients to verbally express their psychiatric complaints should be considered so that writing was chosen as a medium. Another obstacle is the presence of mental fatigue which can be caused by cognitive barriers as the third patient. Although cognitive screening has been carried out and it is stated that there are no obstacles, the magnitude of the variability of cognitive abilities in various types should be a concern for psychiatrists to use this EW method.

Even so, the possibility of significant symptom improvements in all three cases, accompanied by alertness to the emerging of adverse effects, the EW proposed in this paper can be suggested as brief psychotherapy. The term "brief" is meant the shortened face-to-face time of each session, but the actual therapeutic process continues to run outside the therapy room. The patient continues to work on EW at home, and the therapist must be able to encourage patients to do EW independently. By looking at the advantages and disadvantages of this type of therapy, it seems EW is still feasible to be tested in future studies in the future.

**Funding:** This research did not receive any financial support

**Competing Interests:** The authors have declared that no competing interests exist
