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December 2016

Dr. Vince Felitti and the roots of the ACE Study; Expressive writing; Interactive Journaling; Pen, pencil and paper planners


Last month, when I wrote about the work of Dr. Robert Anda and his pioneering work on the Adverse Childhood Experiences (ACE) Study, Steve Allen, PhD, a licensed clinical psychologist and an instructor in the certificate program in Alcohol and Drug Abuse Studies at University of California Berkeley Extension wrote to me.  November 2016 edition 
Dr. Allen, who was the founder and Program Director of the Kaiser Permanente Chemical Dependency Recovery Program at Vallejo, California for 20 years, and served for ten years as Kaiser’s Northern California Chair of Chiefs of Chemical Dependency Services, pointed out that I had neglected to acknowledge Dr. Vince Felitti who was really the inspiration for the early work that birthed the ACE Study.
So, better late than never, I asked Steve to give me his up close and personal perspective on the roots of the ACE Study; and tell of his own experience with Dr. Felitti and the ACE studies at Kaiser. By so doing we can give Dr. Felitti his due recognition, respect and thanks for all he did to educate us about ACEs.
Hear about the firsthand, front seat on the roots of the ACEs Study
When I read David’s Tips and Topics for November, I was happy to see that he was addressing the Adverse Childhood Experiences work. However, I was surprised that he said Dr. Robert Anda was “there at the start,” and that Dr. Vince Felitti and his Kaiser work was not even mentioned.
For those who may not be familiar with Kaiser Permanente, it is the largest prepaid, non-profit, healthcare delivery system in the United States, with the bulk of its services concentrated in California. Kaiser has always provided mental health and chemical dependency services alongside its other medical services. From 1989 until my retirement from Kaiser in 2010, I was privileged to be their Chemical Dependency Services Chair for Northern California. During that time, Dr.Felitti was a physician in Kaiser San Diego’s Department of Preventive Medicine.
Which makes me “there at the start,” too, though I was not aware of it for some time.
Early Discoveries
During the 1980s, in the San Diego Kaiser Weight Program, the physicians made the counter-intuitive observation that patients who were successfully losing weight were the most likely to drop out of treatment. Subsequent exploration with these patients revealed that the great majority of them had unrecognized problems dating back to childhood. Obesity with these people provided hidden benefits; it often was sexually, physically, or emotionally protective for them.
This led to further exploration of Kaiser’s general medical patients, which revealed an unexpectedly high prevalence of adverse childhood experiences. It was at this point that Dr. Felitti invited Dr. Anda and his group at the Centers for Disease Control to design and analyze the series of large-scale studies which documented the prevalence and the astonishing health implications of these childhood experiences.
The Study Sample at Kaiser
The study sample was a group of 17,000 middle-class Kaiser patients, of mixed gender and ethnicity, who were asked the ACE questions as part of a comprehensive medical examination. In terms of prevalence, the study found that less than half of them had an ACE score of 0 (no adverse childhood experience); and one in 14 had a score of 4 or more! That meant there was a lot more trauma history in our patients than we had suspected. (See “Finding Your ACE Score” in last month’s Tips and Topics.)  Your ACE Score
In terms of astonishing health implications, it was found that the compulsive use of nicotine, alcohol, and injected street drugs– as well as a host of other medical problems– increased proportionately in a strong, strikingly graded manner as ACE scores increased.   For example:        
Results for nicotine and injected drug dependence were quite similar, as well as those for chronic obstructive pulmonary disease (COPD), ischemic heart disease, asthma, depression, and other conditions– always a strong, graded increase in conditions as ACE scores increased.
Dr. Felitti’s Mission started at Kaiser
The original article on this study was published in 1998, but long before that, as soon as the results became clear, Dr. Felitti began visiting all of the Kaiser medical facilities to present his findings. This was how I had the opportunity to meet him and to be blown away by the information he was presenting.
He returned a couple of more times after that, with more information and a stronger case. He was on a mission to make all of us at Kaiser attentive to this important connection in the patients we were seeing. Most memorable to me was his presentation to all the Northern California Chemical Dependency staff on ACE and addictions, which convinced me to always use the ACE questions as part of our comprehensive assessments of addicted patients.
I’m including links to the original study
and to the information he presented on addiction
Dr. Felitti’s presentation
as well as a more recent paper confirming these findings with a much larger (54,000 people!) and a more representative sample.  Recent larger study
Thank you, David, for the opportunity to give credit to this great man!”


A couple of weeks ago an article by Sammy Caiola, Health Reporter for my local Sacramento Bee (SacBee) newspaper caught my eye. The headline read: “Is the pen still mightier? The pros and cons of loose leaf vs. laptop“.
Sammy’s SacBee article

Sammy talked about how “writing on paper has a long list of benefits that have largely been forgotten in the age of laptops, iPads and tablets…Journaling has been shown in multiple studies to improve aspects of mood and health, including reduced blood pressure and stress hormone levels, fewer physician visits, improved memory and better eye health.”

Use expressive writing and journaling in the treatment of trauma

Sammy interviewed Jan Haag, a professional creative writer and chair of the journalism department at Sacramento City College for the article. “Regardless of the medium, the most important thing is that people continue to write expressively in whatever way is comfortable…..That’s especially true for people who have experienced trauma, she said, which is why hospitals and therapy groups have long relied on journaling as a tool for coping with stress.”

“Talking about things is therapeutic and helpful, but writing about it and watching grief become art under your hands is a huge and inspiring feeling,” Haag said. “Translating that pain into art is one of the most important things. If nothing else, you’ve gotten it out of you and on the page so it’s not festering inside you. It’s the same thing with real joy.”

In the October 2010 edition of Tips & Topics, I excerpted a Wall Street Journal article by Gwendolyn Bounds: “How Handwriting Trains the Brain Forming Letters Is Key to Learning, Memory, Ideas”. (The Wall Street Journal. October 5, 2010.) She articulated how writing by hand is more than just communication. It engages the brain in learning and has a unique relationship with the brain in composing thoughts and ideas.
October 2010 edition

Use Interactive Journaling ® as an Evidence-Based Practice (EBP) to enhance person-centered change and trauma-informed care

“Interactive Journaling (IJ) as a clinical tool combines elements of bibliotherapy (the presentation of therapeutic material) with structured reflective writing” (Miller, 2014).  Interactive Journaling is on the Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices (NREPP).
In 2014, I wrote an article about Interactive Journaling ® (IJ) that explains how IJ finds the right balance of the structure of EBP with the central importance of the therapeutic alliance to enhance positive self-change.
Interactive Journaling article

In the May 2014 edition of Tips & Topics, Interactive Journaling ® was the focus and how to use IJ in Impaired Driving classes, addiction treatment and mental health settings, as well as with criminal justice populations.
May 2014 edition

For trauma related Journals, here are what The Change Companies has for your consideration:

*    “Trauma in Life – Women”: Trauma in Life Journal

*    “Traumatic Stress & Resilience – Men”: Traumatic Stress & Resilience – Men

*    “Perspective” (Claudia Black):

*    “VOICES” (Stephanie Covington):

*    The MEE Journal System  – the practice of Interactive Journaling® is supportive of trauma informed care in many aspects, including IJ’s reinforcement of personal empowerment and its ability to provide a safe vehicle for communication and self-expression.
MEE Journal System

Discover how Interactive Journaling is also effective in promoting wellness in all people, not just clinical populations
I asked Dr. Deborah Teplow, CEO and co-founder of the Institute for Wellness Education (IWE) to explain how IWE incorporates Interactive Journaling® into its level I coaching certification training,  Take Charge of Your Life: Be Well to Do Well. The course is online and supplemented with live teleconferences.
Here’s is what Deborah had to say:

We use journaling in two ways:

We use My Personal Health Journal to enhance students’ ability to make positive, lasting change in their own wellness.

Journaling corresponds to four (physical, nutritional, financial, and emotional wellness) of the ten units on wellness in the online component of the course. For each of the four units, students complete all the activities in the journal on their own and then participate in online discussions with other students about their journaling experience.

Survey Question #1
In a recent survey, we asked students to rate the value of journaling in their own lives. The results were overwhelmingly positive. (See next page for survey results.)

In response to the following questions, “What would you tell people about what you got out of journaling, or the potential benefits they may get out of it,” students reported the following:

Results on Question #1
*    “I would tell them that it was a life changer and I feel better as a person now.”
*    “Journaling helps you put your thoughts into words, helps you think through the options you have/options you can create for yourself, and it makes it nice to see everything laid out in front of your eyes.”
*    “I would tell them that I learned that small steps can have a big impact. For example, every time I pass my locker, I take a deep breath. This helps me de-stress throughout the day.”
*    “I would tell them that awareness is everything in accomplishing their goals and this program definitely fosters awareness.”
*    “I learned that change doesn’t have to be difficult. It can be easy if you incorporate making changes into your daily life.”

The second way we use journaling is to train students to lead group journaling sessions. Students are trained through live skills practice and rehearsal (“real play”) during weekly teleconferences.

Our graduates lead “Journal Clubs” using My Personal Health Journal and several titles from the “Keep It Direct and Simple” series in a variety of settings, including houses of worship, high schools, and public-health agencies.

Survey Question #2
Please rate (1 = strongly disagree, 7 = strongly agree) the impact of journaling on your self-change process.

Results on Question #2

1.    “Helped me think about my overall wellness.”
2.    “Gave me valuable insights into the self-change process.”
3.    “Enabled me to set goals that are important to me.”
4.    “Gave me new strategies to help support behavior changes I wanted to make.”
5.    “Helped me appreciate how small steps can lead to big changes.”
6.    “Led me to make behavior changes that have “stuck.”
7.    “Overall, I found interactive journaling helpful.”

On average, participants endorsed a level of agreement that favored the “strongly agree” side of the scale.

Here is the latest information on IWE’s wellness coaching courses
Institute for Wellness Education – Wellness Coaching

Miller, W.R (2014). Interactive journaling as a clinical tool. Journal of Mental Health Counseling, 36,(1).


A lot of people use an electronic calendar for their appointments and work schedule. Not me. I have been buying the same AT-A-GLANCE ® Weekly Appointments planner for the last 30 years or more. There are real advantages to going digital and paperless, but I am just old-fashioned.
My trusty weekly planner

Here are a few reasons I like to write with my pen or pencil in my paper planner:

  • I like to use a pencil for tentative appointments rather than writing in pen. I can immediately see it is a tentative appointment waiting confirmation. (I know, I could type in a digital calendar in a different font or color to indicate a tentative appointment, but how is that any less work than just using my pencil?)
  • When I am on the phone planning an appointment, I can keep talking while I grab my planner and leaf though the pages of weeks looking for an open spot. No need to place my cell phone on speaker mode while opening the digital calendar, swiping through the weeks to find a date and time. Just see-at-a-glance while talking.
  • If I want to check back on what airport or airline I used for the same location six months ago or even last year; and which hotel I stayed at, all that is right on the page to see. I know I could copy and paste that information into the digital calendar too, but I think the time to do that is not much different; and I think, harder to retrieve quickly.
Pen, pencil, planner

When it comes to “To Do” lists, no Wunderlist or digital reminder apps for me. I have a page in my pocket paper planner to write on my “To Do” list as tasks arise. Then from that general list I make my daily list of things to do specifically that day. It is such a satisfying feeling to take my pen and scratch out each task as it is done.

Inevitably, there are items on the list I didn’t get to and scratch off the list. This is a visual reminder that once again, I was overambitious and over scheduled myself – sort of like a journal page to initiate a change process to slow down and smell the roses.
This holiday season will you be putting pen or pencil to paper for all those personal holiday greeting cards? Or will you send out a general holiday newsletter by email to all your family and friends like we’ll be doing? Is that progress or have I just now succumbed to the impersonal, keyboarding digital age?
Happy writing….
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