Creative Writing in Healthcare Settings

Core Competencies for Working with the Literary Arts for Personal Development, Health and wellbeing

By Rose Flint, Fiona Hamilton & Claire Williamson ©2004 

Contents

  • What's Required of the Writer in Healthcare?
  • Practicalities Now
  • What is Required of the Healthcare Provider?
  • Future Vision

This document is a distillation of our thoughts and discussions over the past year. Here we aim to set out the conditions necessary for creative writing sessions to be delivered and received effectively in healthcare settings. We hope that this document will provoke discussion and further contributions from all interested parties to the evolution of this vital and exciting field of work.

Introduction

The use of writing as a healing tool has long been recognised in the United States but in the UK the written word is the only major art form which does not have a specific therapeutic training. Yet all over Britain, creative writing tutors are engaging with the medical profession and social services to provide groups, courses and individual sessions within the healthcare remit. As things stand in 2004, the inclusion of writers in healthcare is unregulated and the requirements of the healthcare provider and the writer are not clearly defined. Both writers and healthcare providers need to establish mutual understanding by sharing more information about their work to the other, both need to understand their responsibility to the other, therefore enabling the full benefit of writing to be received by the clients involved. As more and more writing tutors find themselves in situations where the therapeutic value of the work is a clear component, some guidelines for both writers and healthcare providers are necessary.

With any art form used in healthcare, care must always be taken to ensure that the non-therapeutic practice of that creative activity - as a skill to be learned and enjoyed for its own sake - is continued. However, writing workshops intended for educational and recreational purposes in healthcare settings will still experience a therapeutic content, whether this aim is explicit or not. Many writers who choose to teach their craft are not well-equipped to deal with clients who may be experiencing, for instance, depression, mental or physical illness, bereavement or the after-shocks of trauma. Many writers will not have experienced these states themselves and therefore know little about them. For others, their own experiences may be recent or unhealed and the possible emotional content of the work they find themselves engaged with in a healthcare setting may prove to be deeply distressing. Writers are not trained to understand projection or transference, yet these will still arise, creating confusion and even illness in the writers if they do not understand these processes or have no access to appropriate supervision.

Creative writing has a powerful therapeutic value. The use of an emotional-responsive tool such as poetry requires responsibility; real harm can be done by its clumsy use.  Encouraging a client to write from their experience or imagination can unleash very deeply held feeling. Whilst this is the therapeutic value of creative writing, the client may need to be skilfully supported to move forward from a position of pain and distress. A writer who has no knowledge of therapeutic interventions may be unable to assist a client either to face raw and difficult emotions or to integrate them into the whole self.

It is often difficult for the medical profession to integrate writers into the healthcare environment. They do not always have enough information about what the writer’s requirements are and how these should be met. The writer may be viewed as an extra visitor, an impediment to routine, or even someone who makes a client ‘worse’ by allowing them freedom of expression.

With the rise of interest in writing in healthcare and the recognition of its beneficial qualities, the time is ripe for guidelines which provide the best possible working practice in this field.

 What is required of the Writer in Healthcare?

The Writer - Facilitator:

• is a practising writer developing their art

• is able to demonstrate the capacity to set up and manage groups and one-to-one sessions and hold a creative space

• has completed an approved counselling or therapy course and has understanding of psychological dynamics, appropriate boundaries and the necessity of supervision

• has personal experience of the therapeutic benefits of writing

• has understanding of medical practice and a capacity to work alongside healthcare professionals and develop knowledge of particular institutions' working methods

• is able to 'hold' participants in the sessions, by being able to listen closely and attentively, be intuitive, respond appropriately, trust the creative process, be flexible according to the needs and communications of participants

• provides opportunities for creative play, spontaneity, discovery and self-expression using words

• can facilitate exploration of a range of subject matter - immediate personal experience, wider life experience, imagined experience

• is able to set appropriate goals and bring suitable ideas and materials to the sessions

• has a knowledge of literature and of the variety of materials – e.g. novels, poems, plays, film etc - which could be used in the sessions

• contributes to holistic experiences in healthcare environments

• demonstrates a willingness, as appropriate, to work with the whole person – mind, body, spirit, soul.

• is clear about the limits and emphasis of work where artistic activity is the primary focus - understands it is not a 'therapy', nor the facilitator a 'therapist' as defined in psychotherapeutic terms

• is engaged with ongoing questions inherent in work which contains elements of both art and therapy

• is committed to their own personal development

• observes all necessary boundaries

• pays attention to care of themselves mentally and physically, knows their own limitations, obtains adequate supervision, finds appropriate support when necessary

• knows when referral is appropriate and where to refer participants to

• communicates well with participants, staff and funders

• knows their responsibilities within a team or unit and towards funders

• keeps records as agreed

 Practicalities Now

Supervision

•  is essential in every healthcare setting   • needs to be tailored to the work, the client group and setting and agreed in outline at the beginning – e.g. number of sessions, where, when, who pays etc

• should ideally be provided free of charge to the facilitator by a suitable member of staff within the organisation or an external supervisor

• is an indication of the organisation's respect for the work and contributes to the facilitator's sense that the work is valued and supported

Status within healthcare organisations

Respect and recognition within the healthcare organisation enables the creative-therapeutic work to flourish in a positive environment. The Writer-Facilitator needs to feel part of the unit and connected with staff. For this there needs to be

• a member of staff who has the role of ‘link’ person with the facilitator

• good communication between all parties

• ongoing commitment from staff to publicise creative writing sessions in a variety of ways to staff and potential participants so that in time all tiers of the organisation, including management, are fully aware of the work and able to support it

• time given to instructing facilitators on relevant procedures regarding health, safety and other site-specific protocols and willingness to answer questions as they arise

• a telephone contact point within the organisation which participants can use to communicate with the facilitator about bookings or cancellations

Evaluation

Both the Provider and the Writer-Facilitator must be committed to appropriate ongoing evaluation in order to contribute to the positive evolution of the work and assess how it is being received. The outline for how evaluation is to be carried out should be discussed at the outset of a project and reviewed periodically.

Pay and Conditions

As a guideline in 2004, half day £100 minimum, whole day £200 minimum; to include contact time, preparation and travel time. Significant travel expenses paid in addition. Space for administrative work associated with the sessions should be provided.

Contract

It should be clear to participants what they are being offered in a creative writing session. Information about the session may be in written or spoken form, and will include details of matters such as confidentiality, number of sessions and how to contact the facilitator.

Record-keeping

Record-keeping should be agreed in advance between the healthcare provider and the facilitator as necessary and appropriate records kept in a safe location. Participants should be made aware of how records are managed.

What is required of the Healthcare Provider?

The Healthcare provider should:

• understand the therapeutic potential of creative writing for expressing withheld emotion and aiding memory recall  

• understand that the work done in sessions is more to do with the process experienced by the client, than the material produced

• understand their responsibility of respect and confidentiality towards the client

• understand their responsibility of respect and care towards writers

• provide suitable supervision for the writer and ready access to the organisation’s link staff member

• provide counselling support as necessary for clients or information about accessible counselling support

• where appropriate, provide access to clients notes and require record-giving by the writer i.e. additions to notes

• provide adequate space and time for uninterrupted sessions and ensure that each client is allocated enough time to complete sessions without unnecessary interruptions

• provide continuity of time and space for the sessions e.g. same room at the same time each week

• clearly brief the writer in the provider’s rules and regulations e.g. fire procedures, geography, expectations of clients

• clearly identify a member, or members, of staff to assist throughout the duration of the sessions, as appropriate e.g. personal assistance, scribes

• clearly identify a member, or members, of staff to refer clients to the sessions

• ensure an appropriate member of staff attends an initial meeting with the writer, to make clear the purpose and working of the creative-therapeutic activity

• clearly define provision of resources (e.g. paper, pens) before work begins

• provide appropriate space and facilities for the writer to carry out administrative work associated with the sessions

• pay the writer a minimum fee of £200 per day, for a maximum of two groups (of one and a half to two hours) or equivalent one-to-one sessions, or £100 for one half day session

• understand that a great part of the writer’s work is outside contact time with the clients and includes record keeping, material selection, group preparation, supervision and the writer’s own writing

Future Vision

The use of image and metaphor places ‘creative writing therapy’ close to art therapy, and many lessons may be learned from that discipline.

At the root of the training for art therapy lies the ‘therapeutic triangle’ between therapist, client and the art. This could also be the case in creative writing therapy, where the written word would take the place of the visual work.

To practise as an art therapist requires a degree in art. It would seem necessary for those who were engaging with therapeutic writing to also be proven writers. Writers who see themselves as professional, like artists, bring to the therapy session a very deep knowledge of their craft and a different world-view to those who chose non-artistic professions such as healthcare. Since childhood, the writer's life will have been informed by the world of imagination, by creative thought and deed and by observance of the world in which they live. They understand the working of the imagination and the uses of metaphor; they have a clear grasp of form and a broad knowledge of many different kinds of creative writing which they can draw upon very quickly. They are able to express themselves in the medium of words and assist others both emotionally and technically, to do the same. A capacity to empathically enter a shared imaginative space with a client may in itself have healing potential.

In art therapy, many different models are in use, ranging from Gestalt to Freudian. Some art therapists see themselves as closer to psychologist than artist; many practise analytically, some practise transpersonal therapy. An awareness of projection, transference and counter-transference, a knowledge of the effects of trauma in infancy, or later abuse, and a working knowledge of mental illness all form a practical basic training.

But therapeutic writing – or whatever it may be called – may not need such a psychologically oriented approach as Art Therapy. In the American Poetry/Biblio Therapy model, emphasis is placed on the selection of material, careful supervision and a structured approach, although at least basic counselling skills and some kind of qualification as a writer are required before training.

It would seem that the current situation, where unprepared writers go to work with unprepared providers is in need of some regulation, education and clarity. Whilst we do not suggest that all writing in healthcare must become writing therapy, we strongly recommend that all writers in healthcare must have attended at least a basic counselling course and are provided with adequate supervision. We would also suggest that a document outlining the required commitment of providers and writers should be in NHS and Social Services circulation. Alongside this, the future of writing in healthcare should hold the option of a recognised ‘therapy of literature’, validated by an academic body and accepted by the NHS and Social Services, the priority being that the healing potential of words can be safely accessed by those who need it, at whatever level.

Rose Flint, Fiona Hamilton, Claire Williamson 2004

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