Writing Cures

An Introductory Handbook of Writing in Counselling and Therapy

Gillie Bolton, Stephanie Howlett, Colin Lago, Jeannie K. Wright, Gillie Bolton, Stephanie Howlett, Colin Lago, Jeannie K. Wright

• Publisher: Routledge
• Year: 2004
• ISBN:
  9781135444938
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

there is currently little, if any, literature around that covers online counselling, which has its own section in this book notable list of contributors including Anthony Ryle and Stephen Goss this is currently a hot topic, and a growing field.

Part I
Theory and research

Chapter 1
The passion of science, the precision of poetry:¹ therapeutic writing—a review of the literature

Jeannie K.Wright

Introduction

What is it about writing that ‘strengthens’ the writer and how far has research been able to answer some of the questions associated with how ‘writing therapy’ works? Recently, large-scale studies have tended to emerge from a cognitive behavioural perspective (Lepore and Smyth 2002), but this is not the only orientation to investigate therapeutic writing in individual counselling, psychotherapy and group work. It could be argued that ‘writing therapy’ has also been restimulated by the development of narrative approaches (White and Epston 1990; McLeod 1997; Pennebaker and Seagal 1999) and computer-mediated methods where keyboard and cyberspace have replaced pen and paper. This review aims to map major, cross-disciplinary developments in the therapeutic use of writing in the English language over the last 30 years. The use of writing in cognitive analytic therapy and in journal writing will be addressed in later chapters and is not the focus here.

A continuum exists in the growing body of literature on therapeutic writing between the polarities of a ‘scientific’ and a ‘humanities’ approach, or between ‘mastery and mystery’ (Bakan 1969 quoted in McLeod 1994). On an international basis, those practitioners and researchers who come primarily from a literary arts or creative writing background tend to describe the ‘soothing and healing power of poetry’ (Bolton 1999b) for example. Drawing on their experience of clinical practice (Fuchel 1985; Gilbert 1995; Moskowitz 1998) or of facilitating creative writing groups (Bolton 1995, 1999b, 2000; Hunt and Sampson 1998; Hunt 2000) the therapeutic benefits of writing are explored with an enthusiasm verging on the evangelical: ‘Creativity is not a tool. It is a mystery that you enter: an unfolding: an opening process’ (Rogers 1993:105).

Those who follow a more scientific paradigm, from disciplines including immunology, health and social psychology seek to ‘master’ the phenomenon by measuring, explaining, predicting and analysing the results of randomised, controlled trials. The Pennebaker paradigm (Pennebaker and Beall 1986) has been critiqued, replicated and extended in North America, Europe and many other parts of the world (Pennebaker 1990; 1995; 2002). These experiments clearly demonstrate the benefits of writing therapy’ in reducing inhibition and in improving both physical and mental health (eg. Francis and Pennebaker 1992). I would like to stress that I am not seeking to oversimplify the body of literature on writing therapy by structuring the review around the scientific/humanities continuum. If anything, I would agree with Mazza (1999) that both approaches are needed in order to develop the research base and professional practice of writing therapy.

Central to potential users’ concerns and to those of counselling and psychotherapy practitioners, especially those working within the pressures of a brief/ time-limited model, is the question: how can client writing enhance the psychotherapeutic process? Like other expressive therapies, it increases the client’s control of and active engagement in the process: ‘Perhaps there is no other system of psychotherapy in which the client has so much control over the rate, depth and intensity of his or her personal therapeutic work’ (Rasmussen and Tomm 1992:3).

It also allows the client to choose how to assimilate what emerges from the learning, in their own time, which can be less pressured than in ‘talking therapies’ (Lange 1994).

Comparisons between vocal and written expressions of feeling about traumatic events have been analysed (Murray and Segal 1994) and would suggest that there is similar emotional processing by vocal and written expressions of feeling. The need for caution once fleeting spoken thoughts and feelings are made more permanent and open to scrutiny in writing is an important limitation of writing therapy and will be examined in later chapters.

Definitions of ‘writing therapy’

Defining ‘writing therapy’ is difficult: it is ‘a useful but vague and poorly defined technique’ in Riordan’s (1996:263) summary. Neither is there one neat theoretical model or set of empirical findings to guide the use of therapeutic writing. References to parallels with other expressive and creative therapies, art, movement, drama and music, for example, are clear but there is little systematic explanation as to why writing therapy has not developed to the same extent. For the purposes of this review, I will define writing therapy as ‘client expressive and reflective writing, whether self-generated or suggested by a therapist/researcher’. Therefore, the use of writing by the therapist about the client, such as in case notes or in farewell letters, is not included.

The ‘humanities’ paradigm

The National Association for Poetry Therapy (USA) represents the most developed of the therapies, which uses creative writing (see e.g. Longo 1996). Standards and ethical guidelines are in place in the USA for certified poetry therapists and registered poetry therapists (Mazza 1993:51). Mazza extends an earlier research agenda for poetry therapy and suggests that both quantitative and qualitative research methods are needed at this interface of the arts and psychology.

In the UK, Hunt and Sampson (1998) have edited detailed accounts of current practice in a wide range of British educational and health care settings. The section on theoretical contexts is a tentative collection of ideas, drawing on psychoanalytic theory, linguistics, symbolic interactionism and philosophy, ancient and modern. The need to synthesise and to work across disciplines in the field of writing therapy is apparent.

In her most recent book, Hunt (2000:3) adopts a ‘Horneyan literary-psychoanalytic approach’ to case studies of four ‘highly literate, self-reflective’ women who took part in her ‘Autobiography and the Imagination’ creative writing course. Hunt explores the complexity of her chosen theoretical model with great tenacity, asking important questions about the tension between writing as art and writing as therapy. She points out the limitations of her approach, however, firstly in not focusing on broader cultural or sociological questions of class, gender or ethnicity. There is certainly very little sense of the political awareness of constructivist approaches to be found in some contributions to the field (e.g. Bacigalupe 1996) where questions of social justice and user preference are addressed.

Ethical boundaries are also less than clear: ‘There are considerable risks associated with applying psychodynamic theory to the written and spoken words of people one is working with without the safe-guards which would normally be built into the therapeutic relationship’ (Hunt 2000:191). In autobiographical writing, which exemplifies both ‘process’ and ‘product’, who is best placed to understand the meaning of the writing? Hunt’s interpretations are fraught with such risks.

Gillie Bolton also comes from a background of teaching creative writing. Describing her theoretical model as ‘eclectic’, the humanist tradition predominates, and specifically Rogers and Perls are cited. Bolton’s work is criticised by some for implying that in self-directed therapeutic writing there are no risks. Conversely, as illustrated by the above and by self-report from a range of participants in writing groups, it is this very emphasis on the potential of therapeutic writing for self-help, prevention and self-directedness which makes it such a viable alternative to those who choose to write, whether or not they enter therapy.

In the setting of general medical practice, the question of for whom and under what circumstances writing therapy is most effective is addressed. Those patients for whom it was appropriate to suggest writing therapy (Bolton 2000) included those suffering from problematic life circumstances rather than chronic depression, for example. Those for whom it would not be useful included ‘disturbed or psychotic patients’ who, it was felt, needed more supervision than a general practitioner could offer. Bolton points out that ‘poetry and medicine have gone hand in hand since Apollo was the god of both’ (Bolton 1999a:119).

Drawing from her extensive experience of running workshops with small groups of women (Bolton 1999b) and citing examples from modern poetry written by women, including Sylvia Plath and Anne Sexton, Bolton explores the particular persistence of the savage inner critic in women. She compares writing as therapy to other expressive therapies.

Although there are similarities between Bolton’s methods and those of the Pennebaker paradigm, such as instructing the client/group in ‘writing without thinking’, a clear divergence emerges here. Practitioners and researchers from the cognitive behavioural/scientific end of the continuum, for whom client creativity and imagination are variables to be reduced if possible, underestimate this most important aspect of writing therapy.

Bolton is not a neutral observer. Her stance draws on a long tradition of the therapeutic use of human creativity in general and writing in particular (Abbs 1998): ‘poems are a hotline to our hearts, and we forget this emotional power at our peril’ (Motion 2000:6).

The narrative approach and writing in family and systemic therapy

Family and systemic therapy has been a fruitful area for therapeutic writing, in particular using the narrative approach to encourage clients to re-author their own stories (White and Epston 1990; McLeod 1997). Etherington (2000) counsels and writes in collaboration with two brothers sexually abused by their grandfather, constructing the story of their recovery in diary form, poetry and prose. The resulting narrative examines and overturns many of the conventional power dynamics between client and counsellor and between participant and researcher.

Bacigalupe (1996), practising in an American family therapy and community mental health context, emphasises, like Bolton, the client centredness of writing with and by the client rather than writing about or to the client. The implications and relevance of client writing for working cross-culturally are also highlighted. Bacigalupe also links the participatory basis of writing therapy with the power imbalance within any helping relationship. By writing about particular problem areas, the client becomes expert on their own material thus challenging the boundaries between what White and Epston (1990) call ‘expert knowledge’ and ‘local knowledge’. This is particularly crucial when the social status of the client is inherently subject to discrimination and oppression: ‘The question of writing in therapy is also relevant to discussions about issues of social justice in therapy contexts (e.g. therapists working with minority families). Work in a community health clinic can challenge therapists with questions about gender inequalities, institutionalised racism, evolving ethnic and cultural values and classism’ (Bacigalupe 1996:362). Writing in this context is empowering and inclusive. Examples given from family therapy in Australia and the USA include instances where adolescents and children are encouraged to write about their experience of foster care, for example, and present that writing to the ‘experts’ on the panel of professionals who hold the power to make decisions over their lives.

L’Abate (1991, 1992), a family therapist working in the USA, has contributed significantly to the literature on the use of writing, specifically with distance and programmed writing materials which can be used preventively or in computer-assisted training. Known for his humorous suggestion that counsellors should be advised to tell their clients they must write ‘unless they 1. like you a lot, 2. have plenty of money, 3. have excellent insurance, and 4. want to stay in therapy forever!’ (1992:48), L’Abate questions traditional modes of family psychotherapeutic practice and advocates new techniques, including writing, that do not rely on therapist-patient talk. Rasmussen and Tomm (1992) outline a ‘long brief therapy’ the core of which is ‘respect for the client’s self directedness’ (p. 18).

Pragmatism, and not wanting to succumb to pressures to abandon his interest in psychotherapy in favour of prescribing medication, was largely Rasmussen’s original motivation for using writing with non-psychotic patients. His approach to guided letter writing emerged in response to the time pressures of the Danish health care system and long train journeys incurred by his practice between urban and rural areas. Letters from patients could be read on the train! Within a time-limited model, Rasmussen encourages and supports his clients’ existing resources, including their autonomy and creativity: ‘In this method, clients are coached to search out and find what they need the most and will do so if the therapist doesn’t interfere too much’ (p. 18). Tomm has applied Rasmussen’s approach in psychiatry in Canada, and outlines his clinical findings. There is no evidence of systematic evaluation.

The scientific paradigm

If science is the art of the soluble, then Pennebaker and other empiricists have failed. Four leading American researchers (Esterling et al. 1999:84) admit that, ‘Despite the beneficial effects of writing, it is not entirely clear why it is effective in bringing about such striking physical health and behaviour change’. The beneficial effects of written emotional expression are, however, clearly and precisely recorded and have been subjected to meta-analysis (Smyth 1998). Reviews of core research on written emotional expression and health (Pennebaker 1997; Esterling et al. 1999; Lepore and Smyth 2002) suggest various benefits (see Lowe, Chapter 2 for more detail). Headlines such as ‘The Pen is more Powerful than the Pill’ (Bower 1999) have drawn popular attention to the efficacy of writing. In spite of academic and popular exposure, however, on neither side of the Atlantic is writing ‘part of the mainstream psychotherapeutic armamentarium.’ (Esterling et al. 1999:94).

Offering a critique of and advancing Pennebaker’s early work on writing about traumatic experiences, Lange, Schoutrop and colleagues in the Amsterdam Writing Group have used both quantitative and qualitative studies to highlight effective and ineffective ways of writing about trauma (see Van Zuuren et al. 1999). The methods are directive and involve the therapist giving ‘precise instructions’ to the patient about ‘subject matter, the manner of writing, frequency, the amount of time spent and location’ (Lange 1996:376.) Lange demonstrates through case studies how writing ‘a powerful and “friendly” technique’ (1996:381) results in self-confrontation leading to cognitive reappraisal.

In subsequent studies (Schoutrop et al. 1997a, 1997b; Van Zuuren et al. 1999) the psychologists/researchers inspect the writing in a more open and reflective way. Rather than ‘searching for a direct relation between writing therapy and an outcome measure’ (Van Zuuren et al. 1999:364) the group...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Notes on contributors
• Foreword: PS, make it two
• Acknowledgements
• Introduction: writing cures
• Part I: Theory and research
• Part II: Writing in therapy
• Part III: Writing online
• Part IV: Reflective practice