Creative Writing for Health and Well-Being
Creative writing for health and well-being is a constellation of individual or group-based practices which engage with words and writing for the purposes of creating health and well-being outcomes. This can include the listening to, orating, and reflecting on a wide variety of literature including stories and poems.
Creative writing for health and well-being has emerged from a constellation of arts-based practices which have been explicitly linked to health and well-being, that is, a set of practices which are recognized as having a role in “resolving the social and cultural challenges facing today’s world” (UNESCO 2010, p. 8). With a burgeoning empirical base of evidence of the role and impacts of arts-based practices for health and well-being, there is an increasing acknowledgment that such practices can help “keep us well, aid our recovery and support longer lives better lived [and] help meet major challenges facing health and social care… ageing, long term conditions, loneliness and mental health” (APPG 2017, p. 4).
In a broad sense, it is argued that creative practices have an important and distinctive role in reimagining how we relate to ourselves and the world around us in new ways or, more specifically, being able to facilitate the capabilities to “break with what is supposedly fixed and finished... [so] a person may become freed to glimpse what might be” (Greene 1995, p. 19). More specifically, arts-based practices promote and amplify processes whereby “the act of creation, and our appreciation of it, provides an individual experience that can have positive effects on our physical and mental health and wellbeing” (APPG 2017, p. 10).
Creative writing for health and well-being manifests in a variety of fields including reflective writing, creative writing for therapeutic practices, bibliotherapy, poetry therapy, and the medical humanities (Bolton 2011). As well as these expressive and process-focused forms of writing, it can engage with literary works in a wide variety of genres, including dramatic writing (such as plays and screenplays), fiction (such as novels and short stories), memoir and other kinds of autobiographical writing, poetry, as well as creative nonfiction (such as travel writing when there’s a personal or craft element distinguishing it from journalism or technical writing) (e.g., Bolton and Ihanus 2011). Practices within these genres include freewriting, listing, deep attention description, narrative and stories, working with image and metaphor, creating dialogue, journaling, diaries, blogging, zine writing, writing/use of fiction, writing/use of poetry, autobiography, potted histories of self, letters to self or others, future states, and writing/use comics (Ross 2012).
Such creative writing practices include the use of narrative, poetic, or literary techniques with a focus on emotional expression and/or character development (Bolton 2011). However, a key characteristic, which differentiates creative writing practice from creative writing for health and well-being practice, relates to the relative role and importance of process and product of writing. Whereas creative writing is generally a literary endeavor where the resulting text (product) is judged in terms of its artistic worth, creative writing for health and well-being includes an instrumental element in that the writing process and product are valued for their potential to improve the life of the writer. Such improvements may relate to broad notions of personal development (Hunt 2013), or more specific notions of physical and mental health (Pennebaker 1997), or emotional and social health (Killick and Craig 2011), with overlaps in all of the above.
Creative writing for health and well-being is therefore emerging as a significant and distinct practice for enhancing the health and well-being dimensions of sustainable development. This entry reviews the literature in relation to two increasingly prominent areas of interrelated practices, that is, (1) creative writing for personal development and therapeutic purposes and (2) poetry therapy, a more specific form and focus of creative writing, and concludes with a discussion about future directions of the field.
Creative Writing for Developmental and Therapeutic Purposes
In a broad sense, creative writing practices have been utilized as a tool or pathway for individual change, in terms of a continuum between (1) broad notions of personal and professional development and (2) more specific notions of therapy, with fuzzier boundary notions of therapeutic applications or effects which occupy ground between the former two notions. In practice, these are often interconnected and entangled, and it may be that the context or situation of application which differentiates how the practice manifests and is understood. Indeed, the overlap between developmental and therapeutic aims creates a range of ethical questions and debates in practice where practitioners who are not necessarily trained in therapeutic contexts find themselves dealing with highly sensitive and potentially traumatic material.
In terms of professional development, creative writing can be utilized as “a process of beneficial self-reflective change” (Hunt 2013). Here, creative writing acts as a way to inculcate and support reflective and experiential learning, specifically through a context where, it is claimed, “any issue can be shared relatively fearlessly with a piece of paper… [it] can be ripped up, burned, flushed away; creating it will have helped without rereading” (Bolton 2011, p. 22). One of the most common forms of creative writing is personal journaling and reflective writing, as a way of making sense of a wide range of experiences, but the creative writing of stories and poems is also used to inculcate the integrated development of empathy alongside technical training (Cowen et al. 2016). Journaling, reflective writing, reflective learning, stories, and poems can all function to help the individual explore their own relationship with themselves, others, and the wider, natural world. Specifically, this can include (1) the use of humor and experimental creative writing to disrupt and reposition extreme individualism which can create a sense of isolation and psychological stress, toward interconnectedness and sense of belonging (Wall 2016a, b; Wall and Jarvis 2015), and (2) the use of narrative to help challenge how humans relate to animals and other sustainability issues (Wall et al. 2018, forthcoming). In the context of group or collaborative contexts, the evidence suggests that such processes can generate positive psychological states as well as a sense of connectedness and sense of belonging to others in wider natural environments (Rossetti and Wall 2017; Hunter and Sanderson 2007 and Wall et al. 2017a, b; Bacon 2018).
Exploration of narratives of experience from different perspectives
Reflexive clarification of values, principles, ethics, feelings, and identity
Critical examination of metaphors in daily use
Metaphor “games” to express the otherwise inexpressible
Imaginative acute observation and description (Bolton and Ihanus 2011, p. 168)
As alluded to above, creative writing for therapeutic purposes can take place in many different contexts by a wide range of professionals. In addition to individuals using the creative writing practices on their own or in an online forum, creative writing practices might be employed by clinically trained psychotherapists or professionally accredited counselors as part of long-term one-to-one therapy or support or other health assistant practitioners at the bedside in hospital settings. However, the techniques of creative writing for therapeutic purposes are typically employed in a group setting with a trained or accredited facilitator. Settings can include hospitals of all kinds, hospices, schools, colleges, day treatment centers, public libraries, care homes, primary care settings, rehabilitation clinics, literary festivals, community centers, faith-based spaces and facilities, and even public spaces (e.g., DeSalvo 2000; Bolton and Ihanus 2011).
The application of creative writing practices in group settings can differ on at least three important dimensions: open-closed, aim-population, and in terms of the product-process distinction outlined above (e.g., Nyssen et al. 2016). The first dimension of difference relates to whether the group is open, where there are no or very few restrictions on who can attend, or closed, where the group sessions are designed for a specific group of people or particular group of conditions which need to be carefully managed. An example of an open group is a drop-in reflective writing workshop taking place in a public library, where texts are used to help people find a purpose or sense of belonging. Another example is the use of creative writing practices with the over 50s as a space for generating connection (rather than isolation). An example of a closed group is one formed of individuals who have been referred by their doctor, perhaps held in an in-patient psychiatric ward, where creative writing practices are utilized to reinvigorate memory in a safe space supported by staff who are sensitive to the needs of the participants (Healey et al. 2017).
The second dimension of difference is whether the group is intended to fulfill general developmental and therapeutic goals or whether it is aimed at a specific issue or population. An example of the former might include the use of creative writing practices to build resilience or develop self-esteem with others (Yücesan and Şendurur 2018). An example of the latter might be the use of creative writing practices in a group for people who have experienced a recent bereavement or a group for teenagers excluded from mainstream education (McCulliss and Chamberlain 2013). It may also be possible to have a general goal, such as to elevate mood, and for the group to be aimed at a specific population. An example of this configuration is where a group of people living with dementia is established to bring carers and volunteers together to participate in the writing activities alongside those who have a formal diagnosis (e.g., Shafi 2010; Wexler 2014). Similar practices can also be utilized in bringing caring practitioners and those receiving the care together to enhance the care itself (Rossetti and Wall 2017).
The third dimension of difference in the group setting relates to the creative writing content and techniques deployed. While all creative writing practices for therapeutic purposes have an emphasis on the process (of creative writing and its insights) over product (the artistic quality and distinctiveness), groups may nevertheless differ on how much attention is paid to this distinction. There is evidence that mastery of literary form has therapeutic benefits but this may not be applicable to all groups or settings (Nyssen et al. 2016). For example, some groups may focus on relatively short expressive writing techniques because of a short attention span potentially linked to particular dispositions, conditions, or illnesses (such as dementia, anxiety, depression, or autism) (Shafi 2010). These shorter creative writing practices or activities can be used by practitioners who, for example, work alongside individuals in their beds on stroke rehabilitation wards. In contrast, other groups may attempt longer or more literary forms of creative writing practices such as longer-term life-writing projects whereby the participants write book-length memoirs (DeSalvo 2000).
In terms of the specific format and configuration of a creative writing for health and well-being session, this can vary considerably given the diversity of applications, groups, and occupational groups engaging creative writing for health and well-being outcomes. However, while one-off workshops, of varying lengths, can generate health and well-being outcomes, there is a perspective among some practitioners that a series of sessions at regular intervals is more effective in bringing about beneficial change (Nyssen et al. 2016). This reflects much of the earlier research by Pennebaker (1997) which suggests there may be an initial dip in mood after a creative writing activity before a longer-term gain where the individual has made sense of the new insights and has integrated them into their life. However, this view also reflects more recent evidence which suggests that longer-term interventions or series of them can generate greater longevity of health and well-being impacts (Yalom 2017). Here, open-ended or more typically a set number of interactions such as 6, 10, or 15 sessions reflect group psychotherapy processes and interventions (ibid). During this time, the dynamics of the group change as the members of the group become familiar with each other and find particular (and perhaps new) ways of relating with each other, which in turn can generate a range of well-being outcomes (ibid).
The theoretical orientation of the facilitator also plays a role in the format and configuration of the creative writing for health and well-being outcomes. Whereas some occupational groupings such as psychology, psychiatry, nursing, counseling, and social work are often state-regulated, most countries do not regulate the particular field of creative writing for health and well-being (Nyssen et al. 2016). Therefore, the routes to accreditation or qualification on a global level are currently relatively limited, which in turn means that the qualifications and theoretical orientation of the facilitator can differ widely. Established practitioners may have been trained in related disciplines such as teaching, librarianship, counseling, psychology, psychotherapy, nursing, occupational therapy, psychiatry, and/or psychiatric nursing. Some practitioners may also come into this work primarily as writers and will need further training in understanding group processes and individual psychology. Each of these routes, however, may embody particular ways of understanding (Wall and Perrin 2015) concepts such as wellness and illness (e.g., a relative focus on disorder or positive strengths), facilitation, and therapy and their own role in the therapeutic processes (if indeed at all).
Alongside limited regulation, there are also very few dedicated programs of training in creative writing for health and well-being. Within higher education in the UK, for example, the first Master’s program in Creative Writing for Personal Development ran at the University of Sussex from 1996 to 2010. A Master’s program in Creative Writing for Therapeutic Purposes has been offered by the Metanoia Institute since 2011. Other courses are available as optional units or modules in wider programs of study, such as medicine, holistic or complimentary medicine, and medical humanities. Other options for training include shorter nonaccredited courses. However, although the field of “creative writing for therapeutic purposes” draws on counseling, psychology, education, and literature, it is relatively nascent, and as a stand-alone (inter)discipline, it does not reflect traditional academic boundaries (McCulliss 2012).
Similarly, there are few professional bodies associated with the practices of creative writing for health and well-being, the most notable of which is Lapidus International, the words for well-being association (which is registered in the UK but operates globally). While Lapidus International offers and facilitates personal development opportunities for practitioners in the field and requires its members to abide with a code of ethics, it does not currently offer accreditation or credentialing. However, there are other professional bodies which do take a regulatory and credentialing function which can still apply to the practitioners in the field, but these tend to be specifically related to the practices of poetry therapy, a similar field of practice. Poetry therapy will now be discussed.
Poetry therapy, as a specific discipline within creative writing for health and well-being, has developed a distinct model of practice analogous to other expressive arts therapies (McCulliss 2012). According to Hynes and Hynes-Berry (2011), bibliotherapy, biblio/poetry therapy, and poetry therapy are synonymous in practice and can be understood as “a creative art therapy modality that employs poetry and other forms of evocative literature to achieve therapeutic goals and personal growth” (Golden 2000, p. 125). Processes may include the reading, listening, writing, and/or the creation of poetry which promotes self-expression and self-understanding and also further interaction subsequent to the poetry which acts as a catalyst for self-expression, self-understanding, and sensemaking, as well as the disclosure of that sensemaking as a form of existential knowledge (Hynes and Hynes-Berry 2011; Mazza 2017b).
As such, these processes, especially the writing of narrative, can contribute to the creation of intrapsychic coherence and the development of a more stable personal identity. In particular, the symbolic functioning that is often problematic in states or stages of psychosis can be addressed through the writing and rewriting of constructs or signifiers with support of trained facilitators or therapists (King et al. 2013). This is particularly the case when there is a focus on the processes and techniques of writing rather than solely on self-expression, and this is why professional writers can sometimes be deployed during poetry therapy alongside therapists, as they can offer more precise guidance and support around writing technique than health professionals alone (ibid).
The empirical evidence for the impacts of poetry therapy is now long standing and includes development (Erikson 1963), personality integration (Butler 1974), “empathetic friendship” and memory (Reiter 1994), and the alleviation of the effects of mental and physical disabilities such as dementia through a sense of connectedness (Wexler 2014). Similarly, Simecek and Rumbold’s (2016) empirical work examines the positive effects of poetry therapy in relation to psychological and therapeutic settings for the treatment of dementia, depression, and schizophrenia, in the context of prisons and care homes for the elderly. In contrast, Croom (2014) provides a more extensive discussion around the effects activated in poetry therapy linking them to broader notions of well-being. Here, he discusses a variety of effects in relation to the state of “flow,” where a variety of effects are activated: positive emotion and engagement, relationships, meaning, and sense of accomplishment. However, although poetry therapy may facilitate emotional regulation, there may not always be a direct and positive relationship between the application of poetry therapy and mood, particularly when used with psychotic patients when outcomes can be more variable (Parastoo et al. 2016). This again echoes earlier findings in similar research studies (Pennebaker 1997).
The form of existential knowledge generated by poetry therapy promotes engagement with the “whole being” of the writer-reader, encompassing personal becoming and the development of emotions, memories, dreams, emotions, motives, and cognition through reflective practices. As such, poetry therapy utilizes the functions of language in terms of communication, observing and explicating different perspectives, which combine metacognition and meta-emotion to promote meta-reflection (Ihanus 2016). In this way, poetry therapy can be understood as the interaction or intersection of three components: literature, client(s), and the trained facilitator or therapist. As such, poetry therapy is inseparable from the creative arts and psychology, and given its link with language and words, a special significance lies in the literary arts and in the process of literary creation. This approach to poetry therapy has developed from the use of “imaginative literature to diagnose and treat emotional problems” (Russell and Shrodes 1950), whereby a therapist or facilitator uses published poems depending on or related to a client’s mood (McArdle and Byrt 2001).
Here, writing may be part of the therapeutic process, but such writing activity may not only be a “prelude” for guided discussion, but the original writing itself may also be material for discussion and so tends to have double catalytic effect (Hynes and Hynes-Berry 2011). From this perspective poetry therapy is interactive, facilitating emotional catharsis as well as attempts to bring to awareness underlying tensions (McArdle and Byrt 2001). However, as well as poems being written by clients during the therapeutic process, the therapist themselves may also write poems to intentionally highlight ideas relevant to the therapeutic process or to give a response to the client. Indeed, earlier work by Harrower (1972) demonstrated how the therapist’s own experience in poetry can help enrich the therapeutic process in dialectical terms.
An alternative approach to poetry therapy is based on cognitive methods linked to cognitive behavioral therapy and a relatively less direct relationship with the facilitator or therapist (an approach which is more commonly referred to as cognitive bibliotherapy or reading bibliotherapy) (McCulliss 2012). Here, the facilitator or therapist assigns the client readings from identified self-help books or manuals in addition to other tasks in a workbook. In practice, the reading of the books and manuals can be combined with therapeutic writing and be guided more directly by a therapist. However, although there is evidence which suggests that these self-completed workbooks used without direct contact with a therapist are also able to reduce anxiety and depression, there is controversy about the maintenance of improvements over time (McArdle and Byrt 2001). These concerns echo the longitudinal dynamics of therapy over longer periods of time (Yalom 2017).
Receptive/prescriptive – this stage introduces and frames poetry therapy and writing into the setting, including the introduction of a published poem or other form of literature in order to elicit and validate emotional responses and to encourage self-disclosure and group dialogue.
Expressive/creative – this stage introduces a writing activity/practice, where a writing exercise or prompt is used to promote and facilitate self-expression and to enable participants to share feelings in expressive and safe way and so increase self-understanding.
Symbolic/ceremonial – this stage draws on and makes sense of the situation using metaphors, rituals, symbols, storytelling, narrative, and performance, as a means to deal with life transitions.
In terms of the selection of literature to utilize within a poetry therapy session, the receptive/prescriptive component of poetry therapy emphasizes the use of a poem or other piece of literature which relates to the client’s mood or has the potential to facilitate the evocation of their current emotional state and elicit responses. This matching or connecting of the mood of the poem and the client is termed the isoprinciple and highlights the role of such resonances in helping the client express their feelings even when the client feels reluctant to express difficult emotions through other means (Mazza 2017b). Indeed, a significant emotional contrast between the client’s mood and the poem’s mood may make it difficult to establish a therapeutic relationship and engagement during the therapeutic process, so working with the isoprinciple can help avoid such problems (Hynes and Hynes-Berry 2011).
The value of the literature selected can be assessed in terms of its compactness, rhythm, sound effects, imagery, and concern with human nature and consciousness (Chavis 1986), so it can synchronically act on a multiplicity of levels including emotional, cognitive, and social and deliver the potential to strengthen senses, to liberate painful experiences, to reduce emotional tension, and to enlarge the field of consciousness (Mazza 2017b). In this way, poetic truth can be told/evoked in a way that everyone can be touched and begin to experience personal truth and meanings on the basis of personal life story (Hynes and Hynes-Berry 2011; Wall and Rossetti 2013). That is, metaphors can enable people to understand the complicated phenomena of life in holistic ways, acting as a bridge between the external and internal worlds of the client “that are often complex, contradictory, and even dialectical” (Furman 2007, p. 2). This applies to the reading or writing of poems in the forms outlined earlier in this entry and can also include pre-structured writing (where a specific instruction related to form or content is given to a person or group), the use of sentence stems (e.g., if you knew me... I wish...), the use of a selected line or lines of a poem, or acrostic writing (e.g., whereby the first letter of each line spells out a word or message) (Mazza 2017b).
It is through these processes that the development of personal identity and repair of symbolic functioning can stabilize the imagery of schizophrenic patients and protect them from its more catastrophic effects (King et al. 2013). In many cases therapists help to clarify the meaning of the client’s metaphors which in turn clarifies the client’s existential being or concrete situation (Rojcewicz 2001) and also the client’s voice to validate their own personal experiences (Bolton 2011). In this way, some argue that a goal of poetry therapy is to enable the client to create more meaningful metaphors or symbols for themselves (McArdle and Byrt 2001; Hynes and Hynes-Berry 2011; Wall and Rossetti 2013).
The International Federation for Biblio/Poetry Therapy (IFBPT), established in 1980 in the USA, with a remit to set “standards of excellence in the training and credentialing of practitioners in the field of biblio/poetry therapy and authorizes qualified individuals to practice as mentor/supervisors” (IFBPT 2018).
The International Academy for Poetry Therapy (iaPOETRY), established in the USA in 2012 and has also expanded to the UK, is “a credentialing organization… [who aims] to build and sustain this community by offering one another mutual support and encouragement” (iaPOETRY 2018).
Both bodies offer a similar structured training program which requires incoming trainees to have an academic background in both literature and psychology and is based on closely supervised facilitation alongside didactic study and peer learning. Other umbrella or interest organizations which are associated with the practice but which do not yet currently offer credentialing include Lapidus International (see earlier), the National Association for Poetry Therapy in the USA, the Finnish Association for Bibliotherapy (founded in 1981), the Irish Poetry Therapy Network, the Hungarian Bibliotherapy Association, and the Lithuanian Association for Bibliotherapy (founded in 2017). These organizations typically hold conferences, produce newsletters and journals, and are often an entry point for people looking for collegiality and support.
Conclusions and Future Directions
The range of practices encompassed by the field of creative writing for health and well-being are currently vast and will continue to grow as arts practices are combined in new and creative ways. For example, although poetry therapy already includes a wide range of art forms (Mazza 2007), there is increasing work integrating physical movement as a form of poetry and as a form of reorientation toward poetic inquiry and practice (Mazza 2017b). There is also an emerging recognition of other everyday activities which might also have an impact on health and well-being (APPG 2017). Whereas some of these activities may be articulated as “sedentary leisure pursuits, such as television viewing and playing computer games” (APPG 2017, p. 93), there is also the emergence of new frames of reference which recognize the role of such activities in relation to sensemaking and reconfiguring one’s own self-understandings, perhaps using some of the therapeutic processes discussed above (such as the reflexive clarification of values).
An example of this relates to applied fantasy for health and well-being, where the particular fantasy of science fiction can help engage new perspectives (King 2018, forthcoming) (see entry on Applied Fantasy for Health and Wellbeing). Indeed, this resonates with Williamson and Wright’s (2018) fundamental critique about the role of creativity in writing to generate therapeutic outcomes, reinvigorating the process/product debate where the most crucial dimension is the productive, generative developmental outcomes of process rather than the precision or aesthetic qualities of the final product of writing. It is expected other practices can be legitimized by such a debate and that such practices will continue to develop over time to tackle the issues of health and well-being. There may also be potential for focusing such practices on generating even more complex and multifaceted outcomes such as the other aspects of the sustainable development goals in a more integrated way.
However, along with such developments which further open up the space of therapeutic application, there will be continued concern about who should be offering such applications, how they should be trained, and who should regulate them from an ethical and moral standpoint (APPG 2017). In terms of research, the development and empirical investigation of these new practices are likely to receive attention particularly in relation to methodological diversity (Williamson and Wright 2018) and also in terms of clinical effectiveness when applied to (1) specific groups such as people with schizophrenia, depression, and cancer and (2) specific circumstances such as illness, existential situation, and intelligence.
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