REWRITALIZE: Participatory creative writing groups led by authors in collaboration with mental health care professionals for people experiencing severe mental illness.
Introduction
REWRITALIZE is the result of an identified lack of opportunity for creative activities within psychiatric care and recovery in Denmark. Service users (both in- and outpatients) have little if any access to creative expression or participation in arts projects. Within the health care system, it has, however, become apparent that medicine alone cannot always treat/heal/cure mental health illness. A more holistic approach is called for where social, existential and aesthetic needs are met, in addition to medical needs.
With the introduction of the Center for Arts and Mental health, a multi arts center at Amager Psychiatric Hospital in Copenhagen in 2017, we initiated the project REWRITALIZE, which is a participatory writing project and a creative intervention in mental health care. REWRITALIZE was led by six professional Danish authors in collaboration with mental health care professionals.
Our aim for REWRITALIZE was twofold: firstly, to develop guidelines to ensure identical methods for further practice and research; secondly, to identify the mechanisms of the creative group intervention. To that end, we collected empirical data based on questionnaires and qualitative interviews in order to identify and conceptualize themes that could explain connections between psychopathology and recovery processes. Our overall purpose was to promote recovery-oriented interventions in psychiatric care (Bundesen, Tomsen, Rosenbaum & Kristensen, 2019).
In this article, we will describe the development of REWRITALIZE as a concept, how the creative writing courses were structured and organized, and how we developed our guidelines. The article will also present some of the preliminary qualitative outcomes associated with participating in a creative writing group for service users experiencing mental health illness. In addition, we will highlight some of the challenges that we encountered.
REWRITALIZE: Participatory creative writing courses
Participatory arts, including shared reading and creative writing, have been used in the Arts and Health field as therapeutic approaches in both physical and mental health care, showing effects such as boosting immune markers, reducing anxiety and depression (Nyssen et al., 2016), improving the lives of vulnerable groups, and supporting recovery (Stickley, Wright & Slade, 2018). Writing to promote mental health wellbeing involves different techniques, concepts and methodologies, including “expressive writing”, “narrative therapy”, “creative writing”, “poetry writing” and “life story writing”. In mental health care, specialized interventions for anti-stigmatization in schizophrenia focusing on “narrative enhancement and cognitive therapy writing” (Yanos, Roe & Lysaker, 2011) have been developed, but in our preparatory work we found that the conceptualization of the positive effects on how, why and with whom writing can be beneficial and promote wellbeing is limiting. In order to assess the inherent possibilities of creative writing for recovery, a research project was thus developed. Our research group consisted of six renowned Danish fiction authors, three psychiatrists, one philosopher and two psychiatric service-users. The project was funded by the Danish Arts Council, SIND (National Association for Mental Health) and Amager Psychiatric Hospital, Copenhagen.
During 2017 and 2018, a number of writing groups commenced. All the creative writing groups were conducted by a professional author-facilitator in collaboration with a mental health care professional and took place in various settings and with different durations:
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1 course of 14 weeks in a municipal treatment center for people suffering mental illness and substance abuse
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4 courses of 3 weeks in the outpatient clinic, Psychiatric Hospital Amager
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1 course of 20 weeks in the outpatient clinic, Psychiatric Hospital Amager
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1 course of 8 weeks at the National Gallery of Denmark (writing stimulated by art objects)
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4 courses of 14+1 weeks at the outpatient clinic, Psychiatric Hospital Amager
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1 course of 14+1 week at an open ward for first onset of psychosis, Psychiatric Hospital Amager
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1 course of 14+1 weeks at the Clinic for Psychotherapy, Psychiatric Center Copenhagen
When designing the creative writing courses, we focused on the format of the artistic workshop (Hölscher, 2020) as a way of delivering the participatory creative writing as a creative adjuvant intervention in psychiatric treatment. One of our guiding principles behind the initiative was to develop a playful atmosphere in the group that could conceivably enable the participants to bypass defense mechanisms and safeguard against the anxiety that is often connected with psychotherapy and clinically formulated interventions. To this end, we considered the collaboration between the author and the mental health care professionals as a two-fold expertise that was necessary to establish an environment that was both creative and safe. This makes the writing group a hybrid between a psychotherapy group and an art workshop, combining the strength of creative and playful exploration with the structure of the therapeutic intervention.
The aim was to develop an intervention with a structure that was easy to replicate, at the same time as the author-facilitator had scope for creative improvisation together with our existing knowledge about group dynamics, creativity and psychopathology. The structure for the writing courses was inspired by psychodynamic and phenomenological thinking, building on concepts such as resonance, retroactivity, mentalization, and the creative texts as transitional phenomena, play and containment. For example, we regarded the texts to be what the psychoanalyst Winnicott termed “transitional phenomena”, objects which are “me-yet-not-me” (Winnicott, 1953) and which externalize and organize inner phenomena in a way that makes it possible to investigate them, play with them, and share them with others. We were also guided by the function of the exchange of textual outcomes in the group, in which both the crafting of the texts, but also the reflective processes of receiving comments from the author-facilitator and peers are considered part of a mentalization process leading to recovery (Karterud, 2011).
To ensure best practice, we incorporated ethical considerations to ‘Do No Harm’ as proposed by Jensen (2014) and White (2011). The service users’ suitability for participation in the creative writing activities was established through an assessment by the mental health care team; interviews were also conducted prior to the onset of the group activity. Service users’ diagnoses included psychosis, post-traumatic stress disorder (PTSD) and borderline personality disorder. All staff received monthly group supervision from a senior psychiatrist. The supervision served the purpose of discussing the writing exercises and the reactions in the groups. It was important to continually address the relation of the author-facilitator and the co-therapist (one of the psychiatrists) and their roles and responsibilities in the groups.
The guidelines
It was essential for the REWRITALIZE project to include the authors as part of the research team as well as co-producers of the development for the guidelines. The guidelines explain the structure of the writing course, starting with how the initial interviews are conducted, and further describes the intentions for each of the creative writing sessions, the importance of the group interaction and dynamics and how the roles of all the participants are clearly defined, the structure of the course, and the aims of the sessions and specific writing exercises.
The course
The course is structured with different progressive phases consisting of a start, a middle and an end. Each session has an aim and a writing focus. Examples includes: the purpose is to greet each other; an introductory round is held where everyone is asked to introduce themselves by name and mention the last good reading or writing experience that they have had.
The focus of the writing exercise is to get a start with the writing and to establish oneself in the group and to feel that one can produce text/overcome writing anxiety, as well as overcoming the ‘inner schoolteacher’ and use shorter flow exercises. The exercises are all designed as stimuli for creative writing with no specific outcome in mind but offer stylistic triggers that help to start and structure the writing. Exercise examples are: 1) Texts using anaphors, for example Joe Brainard: “I remember” (Brainard, 2012) or Peter Adolphsen: “I cannot remember” (Adolphsen, 2018); 2) Write about a situation from your morning that includes at least three of your senses; 3) Write an end to a sentence from a literary text by Kafka or a fairy tale by Grimm.
Different exercises are suggested for each stage and session depending on the psychological state of the group dynamics, and activities are designed with a special focus on cultivating reflective competencies about the writing work in the group. Guidelines for and examples of structure of the sessions are described in order to ensure consistency. A catalogue of creative writing exercises that is not meant as an exhaustive collection, but rather as inspirational collection of examples, has also been developed.
The group
For the group to be a safe containing space for the participants, it is important that there is a clear division of roles between the author-facilitator and the health professional. The participants have joined the group because of an interest in literary writing, and they are recruited by a healthcare professional who has found this offer relevant for the individual participant.
The social reorganization that takes place around the activity of the writing group is important. The author-facilitator makes himself/herself known as the group’s facilitator and informs the group about the day’s programme. The participants are encouraged to introduce themselves by name and say a little about their experiences with literature. The mental health professional states his/her specific role as the person responsible for keeping the workshop within the given framework. Everyone is a participant and not a “patient” or “therapist”. There is no explicit discussion of treatment/psychological issues; however, such issues are discussed when/if they come up in the writing as a literary phenomenon with a function in the text. It is important to stress the concept of what is known as “narrative distance”, emphasized by Aristoteles in his Poetics, that the “I” of the text is not the same as the experiencing “I”. In this way, the topic of discussion in the creative writing sessions is always centred on the “I” of the text, which may share autobiographical details with the writer of the text, but they are considered different entities. Autobiographical material is discussed as a literary work on the same level as a fictional literary work focusing on form, style, narration, voice, topic and so forth. All participants are encouraged to comment on the texts and not on the authors. During the course everyone builds a social identity in the group as reader and writer, and the written texts function as a third shared space between “I-Thou”.
Findings
Before participating in the creative writing sessions, the service users took part in qualitative clinical interviews, clarifying social and personal developmental background. We interviewed the participants again six months after the end of the writing sessions with a focus on clarifying the impact of participating in a creative writing group dynamic.
In the retrospective interviews some participants reported that they felt that the writing group had been a free space from a negative illness identity and expressed the value of the facilitator being a professional fiction author. After participating in a weekly workshop for 15 weeks, Anne (38 years old) states:
It is important that it was a professional author leading the group, because the respect for the artistic discipline is important. The artistic language is important. Fiction language and poetry is more accommodating towards other rules and norms. You can improve a text and make it more precise, but you can never write anything wrong. It was a relief to let go of the pressure to perform that has been a burden all my life. I would never have come if it had been a psychotherapy group.
For Anne, it was important to be in a space where there were no wrongs. The creative writing groups provided a space that enables her to let go of a load that has been weighing her down.
An example of the importance of symbolization, where the creative writing techniques enabled verbalization of an ineffable phenomena and prompted ownership of one’s thoughts, is expressed by Susan (62 years old). Susan comments on how her two inner ‘voices’ were able to have a dialogue through a written text and that she could take ownership over the ‘voices’ in this way:
[…] I had always attempted to explain to other people […] how difficult it was to me, but no one could understand. There was always this reality that I could not bring with me into reality, which meant that there were two voices inside of me, the light and the dark. But I managed to write a text where the two voices were able to speak to each other. It was great to write that text. Because there was a distance in there which made it possible to say it aloud and relate to it as something that did not own me, but rather as something that I owned.
For Susan, the writing created a safe space that enabled her to synthesize inner phenomena, integrate past traumatic experiences and explore them from a distance, which made it easier for her to reflect on and relate to them. Susan also explained the importance of sharing her texts:
For me it has had a tremendous impact on my life to have a practice of writing fiction. I need to have an idea that my text will be read by others, that it will be part of some kind of communication. It is very rewarding to be able to share in fictive form with others.
Another participant, Maria (37 years old) highlighted the playful atmosphere of the group and her experience of the written texts as kind of toys:
The text becomes more like a toy, a toy you can play with when you feel bad. It makes the process more tangible and simpler […] and an aid to express yourself, also in relation to others, and to not be so afraid of the words that are uttered or written. That is what matters.
The findings illustrate that Anne, Susan and Maria all benefited from participating in the writing sessions. They all commented on the importance of making connections with themselves and with others through writing and sharing creative texts in a playful and containing atmosphere. Further findings from our research showed that participating in the exercise of poetic and literary expressions has in different ways helped the participants improve feelings of self-esteem, transform the basic trust in themselves, and alter the reflections upon themselves in different social situations (Bundesen & Rosenbaum, IN PRESS).
Challenges and reflections
REWRITALIZE aimed to bridge the gap between arts and mental health care by considering two kinds of professional expertise: that of the professional writer and that of the mental health care professional. In this project, these two kinds of professional knowledge are qualitatively different, but considered to have equal worth. A third kind of expertise and knowledge was offered by the service users. The inclusive approach has precipitated two levels of challenges: Firstly, the internal discussions regarding the paradigm clash between the arts and mental health care, and secondly, the external discussions concerning funding. The internal process of establishing a mutual understanding about the goal of creating creative intervention for mental health care service users raised fundamental questions. Among other questions, one question that was pertinent and addressed was how to progressively structure a creative intervention without killing the very core of creativity, and in addition leaving room for the author-facilitators’ expertise in improvisation and creative intuition. This question remains unresolved.
All the authors have extensive experience of teaching creative writing, but in this project they were encouraged to participate in other authors’ workshops and to attend educational seminars introducing basic topics in the fields of psychopathology, psychotherapy and language (philosophical discussions about the relationship between subjectivity and language that is relevant in relation to both the emergence of psychopathology and its ‘healing’). It was also mandatory to attend the monthly supervision session, which was a cross-sectional group-based session that was new for the authors, who mostly work alone. This process has been demanding but also rewarding for all parties. We have had numerous meetings and debates, and for all three parties (authors, mental health care professionals and service users), it has demanded a willingness to listen to each other and reflect on these different perspectives – both personally and structurally.
The external problem of funding for interdisciplinary projects is common, as such projects often fall outside traditional categories. In our case, the Danish Arts Council funded the authors’ salaries, but not those of the mental health professionals. The two psychiatrists were partly funded by SIND and Psychiatric Hospital Amager, but for the most part the research project has been underfunded and self-financed. Future research depends on funders’ willingness to risk investing in an interdisciplinary field where solid evidence has not yet been generated.
Future plans
In the autumn of 2020, six new writing groups have started, and the guidelines will be evaluated and later published. Furthermore, we are currently planning a four-year project which includes developing guidelines for participatory visual arts produced by an interdisciplinary group of visual artists and mental health care professionals. The project will contribute to art-based recovery-oriented interventions in mental health care.
Ethical considerations
All participants have given consent for their photos and citations to be used in this publication. Participants’ names have been anonymized. The project has been assessed by the ethic committee for Region Hovedstaden (H-19039602) and is registered with the Danish Data Protection Agency.
References
Adolphsen, P. (2018). Jeg kan ikke huske [I cannot remember].1. Edition. Copenhagen: Gyldendal.
Brainard, J. (2012). I remember. London: Notting Hill Editions.
Bundesen, B. Tomsen, D. V., Rosenbaum, B. & Kristensen, K. (2019). Deltagelse i skrivegrupper kan styrke recovery [Participating in writing groups can help recovery]. Tidsskrift for Dansk Sundhedsvæsen, 95(7), 24-33.
Bundesen, B. & Rosenbaum, B. (IN PRESS).REWRITALIZE: Kreative skrivegrupper som del af den psykiatriske behandling [Creative writing groups as part of psychiatric treatment]. Gammelgaard, L. & Raakilde, M. (Eds.). In: Kreativ skrivning i sundhedsfaglige kontekster i Danmark [Creative writing in health practice in Denmark]. Aarhus Universitetsforlag.
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White, M. (2010). Developing guidelines for good practice in participatory arts-in-health-care contexts. Journal of Applied Arts and Health, 1(2), 1139–155. https://doi.org/10.1386/jaah.1.2.139_1
Winnicott, D.W. (1953). Transitional objects and transitional phenomena. A study of the first not-me possession. International Journal of psychoanalysis, 34, 89-97.
Yanos, P.T., Roe, D. & Lysaker, P.H. (2011). Narrative Enhancement and Cognitive Therapy: A New Group-Based Treatment for Internalized Stigma Among Persons with Severe Mental Illness. International Journal of Group Psychotherapy 61(4), 576–595. https://doi.org/10.1521/ijgp.2011.61.4.576
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