Types of writing

I concur with the list that Carol Ross provided – these are tried-and-tested writing suggestions that have therapeutic potential.

Rather than techniques being necessarily applicable to certain diagnoses, my own model is more to do with the level of wellness of the person or the group. The techniques are adapted according to the following continuums:

1. Containing factors

These keep the process safe and accessible.

1. Length of time For someone in distress, writing for a minute might be sufficient.
2. Length of writing Sometimes, for someone withdrawn, one word might be the starting point.
3. Amount of direction/structure Structured suggestions can help with inchoate material.

2. Complexity

Tolerance of complexity is a marker of mental health and I would use TW techniques that encourage nuanced responses with a more well population or with a group that has been meeting for a while. This determines the kinds of writing suggestions I make, such as:

1. metaphor – narrative
2. direct – elaborated
3. first-person – second-person – third-person writing
4. single perspective – multiple perspective.

3. Focus

1. Self – others – wider world These dimensions are all important to understanding experience – as a practitioner, I make judgements about when it is appropriate to encourage writing in a different direction.
2. Pain/distress – positive aspects of life – as above There is evidence that it is important to acknowledge a sense of victimhood before beginning to write a new story.
3. Past – present – future Again all are important but for example, the very elderly often appreciate writing that stays in the moment, especially nature writing.

Settings

My experience with TW includes the following health-care settings in which patients had LTCs, and we worked in groups unless otherwise stated:

1. stroke rehabilitation unit – some group work and one-to-one at the bedside
2. Arts for Older People – in care homes
3. Age Concern day centre
4. day treatment centre for people with severe and enduring mental illness
5. primary care – a health centre attached to a GP practice
6. one-to-one with a dementia patient in her home (referred by an occupational therapist) and, subsequently, on a psychogeriatric inpatient ward.

I have also worked in the following community settings in which participants have often had mental health issues, some severe and enduring, and other LTCs, but these were not the primary reason for attending. For example, the library promotional literature said service users welcome but people were not required to self-identify.

1. St Petroc’s Centre, offering services for street homeless people
2. open-access sessions in public libraries
3. Adult education Writing for Self-Discovery courses
4. Truro Cathedral (was writer-in-residence in 2006).

I also supervised a number of pilot projects in TW by other practitioners, which included the following client groups as part of an Arts Council England-funded Arts in Health project:

1. prisoners at risk of self-harm
2. children in hospital long term
3. long-term unemployed
4. patients at a GP surgery with mild depression
5. women at a clinic for pelvic pain.

The model for my intervention is a psychosocial rather than medical one. However, the outcomes can be measured in medical terms.

There follows a couple of examples that might exemplify some of approaches, justifications and outcomes:

• On the stroke unit, I was part of a multi-art form team offering afternoon sessions for a year as a way of preventing boredom and depression, which, in turn, had an impact on motivation to get well, which, in turn, impacts on length of stay. Elevated mood was seen as a way of making it more likely patients would do the physiotherapy prescribed, for example.

The different art forms worked best with different patients but one characteristic of the writing was that it enabled catharsis and safe expression of emotions, such as despair and hopelessness, which were not permitted with medical staff or family: permission to be oneself is a characteristic of TW.

The average length of time on the unit was 96 days; to justify the intervention financially, this would need to reduce by 4.4 days per patient. The full report is available from: www.artsforhealthcornwall.org.uk/wp-content/uploads/2010/10/Arts-for-Stroke-Rehabilitation-Evaluation.pdf

• On the Arts for Older People project in care homes (also an Arts for Health Cornwall and Isles of Scilly initiative), the improvements were mostly social and psychological – I feel all twinkly (care home resident) – but there are benefits from just moving residents into a group setting that indirectly led to more interaction and motivation to be more mobile, which, in turn, might help with constipation and the other common problems of being sedentary (summarised as poetry makes you poo).

The work can also change perceptions and lead to better care. One participant, relatively young, a retired headmaster, who had had a stroke and was severely depressed, was wheeled in to weekly care home sessions and never spoke nor made eye contact until the sixth session when he contributed one word and then smiled; subsequently, speech therapy was accessed and he made considerable progress.

Victoria Field, 9 May 2013