A Proposal for Including Patient-Generated Web-based Creative Writing Material into Psychotherapy: Advantages and Challenges

Abstract

Creative writing presents both a challenging and promising modality for psychotherapy. Though it has been used in various settings, the application within a session can be difficult. This case study presents a use of a web-based format to engage a resistant patient through her creative writing. Benefits and potential pitfalls of using a patient’s writing in therapy are discussed.

Introduction

Creative writing presents a unique, though problematic, avenue for psychiatric therapy. Psychodynamic principles have long been used to analyze the thematic intent and underlying message in the works of well-known authors, such as Kafka’s classic Metamorphosis. There is also literature on using psychodynamic principles to improve writing skills.¹ However, the use of creative writing for the expressed purpose of therapy remains limited. Time constraints, which limit how much material a therapist could conceivably read, would seem to be a drawback to the medium. However, in the current climate of limited access, and with the rise of web-based treatment options, there may be a place for the therapeutic use of creative writing.

There is a wealth of literature on other forms of therapy based on artistic expression. Different forms of art therapy have been used effectively with eating disorders,^2,3 schizophrenia,⁴ posttraumatic stress disorder (PTSD) in refugee children,⁵ and to help women cope with breast cancer.⁶ Art therapy can even be used in a group setting.⁷ In addition to art therapy, music therapy is gaining ground as a treatment in the mental health field.⁸

Whatever the modality used, as noted by Flood and Phillips,⁹ “The process of creating…may be more important than the actual product or tangible outcome.” The benefit in terms of various mental and psychological health indicators comes firstly from the creative process and then secondarily from connecting an affective component to the art. This was many authors’ conclusions after reviewing several studies on different modalities of what they refer to as “creative interventions,” finding that the particular modality is not as important as that the individual is doing something creative. The creative process, when pursued earnestly, involves digging through one’s experiences, thoughts, and emotions to find something of meaning worth conveying. This depth of self-exploration serves as a re-evaluation, resorting, and hopefully a rediscovering of meaning. This process, though helpful, can be limited when experienced in a vacuum without a psychiatrist there to question assumptions and offer objective interpretation.

Creative writing has been used not as a therapeutic tool but as a pedagogical tool in selective populations. Reisman, et al.,¹⁰ described a workshop for resident physicians as a, “creative outlet for the rigors of medicine.” The goal of the program was to use writing to teach the residents an appreciation or curiosity about their patients’ lives beyond their diseases, to see them as whole people. The stated aim was to help participants reflect on what gives meaning to their work and their lives. In their post-hoc focus groups, the authors also found an increased sense of self-awareness among the participants.

Shapiro, et al.,¹¹ gave a comprehensive view of using creative writing with medical students and residents, referring to the process as “reflective writing.” The goal of this type of structured writing was to develop “situational coping, self-awareness, and joint investigation,” among other benefits. The process involves first careful, introspective writing. Then the work is shared in a small group, which results in “acknowledged vulnerability, risk-taking, and self-disclosure.” Additionally, active listening to the work of others is viewed as an “exercise in mindfulness and presence, including witnessing suffering and confusion experienced by others.” All of this then serves as a practice ground for the doctor-patient interaction.

Creative writing has also been noted as a positive professional endeavor for neurosurgeons.¹² Bernstein hypothesized that the generally non-fiction, reflective essays serve as a catharsis for the surgeon. He also felt that this sort of sharing helps to introduce the physician’s perspective to the patient population, helping to improve the doctor-patient relationship through increased mutual understanding.

Creative writing, similar to other artistic endeavors, provides a creative outlet for reflection for both the beginning student and the seasoned professional. These populations seem to benefit from being able to freely express themselves. The benefits noted or proposed for these specific populations would be desirable in the general patient population from the improved indices of mental health noted in the elderly to the improved self-awareness in the trainees to the cathartic self-expression with the surgeons. The challenge then is adapting these creative modalities to use within the context of one-on-one psychotherapy

A smaller number of articles discuss the use of writing with patients in more of a therapeutic context. Predominantly, writing takes the form of journaling, either to track symptoms or to stimulate active reflection. This has been shown to be beneficial for women with breast cancer,¹³ individuals dealing with growing old,¹⁴ survivors of trauma or stressful events,¹⁵ and mothers experiencing the stress of a newborn in the NICU.¹⁶ Of note, the article by Deters found that everyone in the study benefited from writing, both those in a group instructed to write about the trauma and those in a group instructed to simply write about trivial matters. Overall, there are a multitude of options for therapeutic writing, from expressive writing, storytelling, poetry, the use of metaphors, to very concrete journaling. The benefit appears to lie not in a particular form or style but in creating something external and concrete.

Another study, this one involving German students with a history of trauma, is perhaps illustrative of the manner in which writing produces a benefit. Study groups were divided into “coping” vs. “helping,” with the instructed focus being either describing how they have coped and do cope versus taking more of an advisory stance, offering advice to someone in a similar situation, respectively. Both groups had similar improvements, and, in comparing various aspects of the writing produced and the study outcomes (physician visits, physical symptoms, affectivity), both emotional expression and self-exploration were singled out as “significantly related” to improvements.¹⁷ This then would suggest that aside from the content, or perhaps even the situation, a psychiatrist would gain more ground in focusing on the patient’s ability to express emotion and reflect upon himself or herself whatever the content and form.

Writing can be used in therapy either individually or in a group setting. In either setting, “writing can be used effectively with patients who are reluctant or embarrassed to speak openly.” As put by McArdle, the purpose of expressive writing is to “enable people with mental health problems to enjoy and express themselves, develop creativity and empowerment, affirm identity, and give voice to views and experiences.”¹⁸ The goals of therapeutic writing are directly in line with the goals of any psychotherapy, which is the empowerment and healing of the patient. Ideally this should lead to a positive change in both thoughts and behavior.

The challenge remains, however, to transfer this modality into some manageable form between the therapist and the patient. One possible model is the website www.ficlets.com, though its current purpose is purely recreational. After witnessing a spontaneous catharsis of teenage angst on this internet site,¹⁹ however, I was impressed that even in its present form there is therapeutic potential. The site allows a writer to create a piece within a given character limit (1,024 characters), thus creating at least one limit on the amount of material. This piece, referred to as a “ficlet,” is then posted for other users on the site to read, rate, and/or comment upon. The potential also exists to write a sequel or prequel to someone else’s writing, creating a sense of community or group experience.

Could this format represent a possible avenue for therapeutic interpretation and intervention?

Case Example

A self-described “self-harmer/anorexic,” MelloWings (username) had been in formal treatment for depression for several years. Her history included cutting, unstable relationships, physical abuse, and one suicide attempt. At present, treatment consisted of monthly visits with a psychiatrist, the primary focus of which was medication management. She was on a selective serotonin reuptake inhibitor (SSRI) with what she considered moderate effectiveness.

Appointments with the doctor did not go well. Communication was limited to checking side effects and effectiveness of the medication and, “hurling swears at the doctor.” MelloWings stated, “I just take the medicines. I hate my doctor with a passion.”

Though scheduled for 15 minutes, most sessions ended before the 10-minute mark. The possibility of more in-depth therapy with the psychiatrist was not yet being considered by the psychiatrist or the patient.

During one such session, MelloWings mentioned in an offhanded manner to the psychiatrist that she found the “ficlets” internet site a few months previously via an advertisement on a chat service. She very briefly described the site to the psychiatrist, though it wasn’t until later, after the psychiatrist began to access the site himself, and read, with the patient’s permission, her writing, was he able to learn more about why MelloWings liked using the site.

As she later revealed, MelloWings checked the site several times a day, “to check for comments or notes, but then I get sidetracked and do other things too.” “Other things” included reading what others wrote and reading the blog, but mostly writing short creative works. Outside of this site she did not share writing with others, aside from school assignments. But on the site, she said, “I can abandon my misconceptions about myself or views of other people toward me, and just write.” The site then became a substitute for what should have been the relative safety of a therapeutic relationship with the psychiatrist.

She went on to say, “A couple of times, I will have something on my mind, or something bugging me, and it usually turns into a [story]. It lets me get my feelings out in a way that’s safe. Writing about these things helps me to understand them, to see them in new ways, and to start to heal. I can take the bad stuff out of me, and put it into a character, who may or may not be me.”

According to MelloWings, “Writing allows me to express myself and after writing, I always feel a sense of accomplishment. Writing helps me to solve problems and realize things as well. There have been times when writing has completely turned a bitter mood into something more calm and positive, and the support and comments of my fellow [writers] are always greatly appreciated. It always makes me smile when someone comments on my writing.”

Practice Point: The Value of Web-Based Writing Therapy in the Psychiatric Setting

This case demonstrates some of the key issues that may be involved when a patient communicates differently when face-to-face with the psychiatrist as opposed to “journaling” with anonymous others on a website. MelloWings had significant negative transference toward the psychiatrist, associating him with “just medications.” Also, time limits of modern medical practice limited their time together, and, in this case, both parties were probably relieved to have their 15 minutes over, rather than taking (or having) the time to work through resistance. But in sharp contrast to the patient’s utter unwillingness to discuss matters with the psychiatrist, she placed deep and personal content on a publicly accessible website.

In the view of one participant on the site, in addition to the safety of the written word, the online written word provides a safe distance to put things out there, as he put it, “to take creative risks without putting too much at stake.” Though this anonymity and sense of security may not be ideal, as it may perpetuate isolative behaviors over directly facing issues, it does at least allow for issues to come to the surface where they can begin to be addressed. This very safety and willingness to express uncomfortable emotions could be a potential benefit to a web-based writing therapy.

In the case of MelloWings, the writing so far had been self-directed. The feedback was from peers, an assortment of individuals of varied backgrounds, ages, and career fields. Their intent may have been genuine, jocular, or derisive. No one person directed or in any way moderated the commentary on a given piece or its author. People were free to come and go, signing on to make a few snide comments or write a novel’s worth of material. Despite all this chaos, however, MelloWings thought that her writing on the site was far more therapeutic than her time with a thoroughly trained practitioner. She even went so far as to refer to the creative writing process as her “earthly savior.” Whether this “salvation” led to any real progress or merely reinforced existing patterns remains to be seen.

It should not be surprising that some patients would see benefits from a web-based anonymous interaction. As put by Gabbard, the need to be known, validated, and recognized may be as “fundamental as the wish to understand in the course of dynamic therapy.”²⁰ Yet, as in the case example, resistance quite often all but precludes this from happening. A patient may want to be known but fear being judged. As the stated goal of therapy is to address or change some aspect of the patient or his or her life, the resistance to being known may be more accurately characterized as a resistance to change. There may also be a discomfort with the language of therapy, more a question of how to communicate rather than an entrenched desire not to communicate.

The creative aspect of web-based anonymous participation, that a writer is able to express himself or herself without having to immediately own the emotional or manifest content, provides a possible early inroad through resistance. This possibility has been described in a case study by Morrice²¹ in which poetry was used in conjunction or as a part of therapy. The key then in joining creative writing and therapy is moving the patient beyond simply expressing the difficult emotions to actually addressing and challenging them.

Using a web-based format, but modifying it such that patient and psychiatrist are speaking to each other via the patient’s creative writing, might make it more feasible to use creative writing as a psychotherapy technique. First of all, the open-access, web-based format allows for flexible access by both the psychiatrist and patient, rather than forcing a set time to sit together and quietly read in the same room. In this way, provided the patient openly gives the psychiatrist his or her screen name or pseudonym, all posted content can be easily available for interpretation and discussion. Secondly, “character limits,” the way the site limits the length of each story, can provide a preset quanta for expressive writing.

Case Example, Continued

After MelloWings made the casual mention of the website to her psychiatrist, he checked it out for himself. He then proposed at their next session that he read the content she posted and possibly discuss it during their next session. She agreed and gave him her screen name, and though she was seemingly very reluctant to discuss anything with the psychiatrist, she seemed accepting of the idea of the psychiatrist reading what she wrote.

Until the use of the web-based writing, therapy with MelloWings consisted of little more than medication management—the patient more likely maintaining pathology than making progress. By bringing her writing into the discussions, though time consuming, the sessions were more productive than the existing communications stalemate. The following is a sample interaction between the psychiatrist and MelloWings showing how the psychiatrist was able to use MelloWings’s writing as an inroad through the apparent resistance.

Doctor: How are things going this week?

MelloWings: Fine.

Doctor: I notice you say that most weeks. But, the story you wrote this week seems to have an angry feel to it. Is that how you’ve been feeling?

MelloWings: Maybe.

Doctor: Can you tell me why you might be feeling angry?

MelloWings: Because you suck.

Doctor: That’s another thing you say most weeks, but I haven’t quite figured out how, in your view, I suck. Is it because you see me like this character here or more like this character?

Even in MelloWings’s own estimation, the content of her stories reflected issues and emotional conflicts on her mind. Here, rather than an open-ended discussion of feelings of hostility, the patient explored the issue in a compare-and-contrast manner in relation to the proffered fictional work. Whether her unwillingness to talk represented hostile dependency or narcissism or some other issues, by allowing her to bring the content into the room on her terms, as fictional stories, the psychiatrist was able to establish a bridge to transition the reluctant patient to openly discussing issues. Even MelloWings’s selection of which story or stories to discuss provided insight into what she felt was most important at a given time. Finally, the simple act of taking the time to consider the material, in which MelloWings was apparently emotionally invested, served as a way to strengthen the therapeutic alliance.

Web Survey Results

In order to gather preliminary data about attitudes and experiences of participants on the site, a brief survey was created using another website, surveymonkey.com, using a Likert scale for three questions (Table 1) with 1 being “no effect,” 3 being “some effect,” and 5 being “great effect.” The survey also asked a yes/no question about other online writing aside from the creative writing on the website ficlets.com. An invitation to participate in the survey was then posted on the site’s internal blog, a weekly update from the site administrator accessible via a link on the welcome page. The invitation indicated that the purpose was for a research paper looking into the possible therapeutic benefits of creative writing. Though not identified by name, the writer of the survey was identified by his pseudonym on the site.

TABLE 1.

Questions from internet survey

How much does writing alleviate or help improve a negative mood for you? How much does feedback on your writing alleviate or improve a negative mood? How much do you think issues, concerns, and/or feelings from your life wind up in your creative writing?

Those completing the survey self-selected to do so and consisted of individuals signed into the system and therefore presumably at least somewhat active on the site. Over the course of a month, roughly 25,000 unique users sign on to the site, with 500 of those being new users over the course of that month. Only 44 users completed the survey, which was posted as available for roughly a week, representing another limitation of the study.

Of this small convenience sample, 46.5 percent of the respondents indicated that they maintain some form of “blog” or online journal in addition to participating in the creative writing on ficlets. The results of the three Likert scale questions can be found in Table 2.

TABLE 2.

Results of internet survey

N=44	Question 1	Question 2	Question 3
Mean	4.02	4.7	4.16
Mode	4 (23 responses)	5 (34 responses)	5 (20 responses)
Standard Deviation	0.79	0.59	0.91

Conclusion

There are potential pitfalls to including patient-generated, web-based creative material into psychotherapy. Therapy should not devolve into constructive criticism on writing styles but should instead focus on either the manifest or underlying emotional content and significance of the work.

It remains unclear whether professional intervention or interaction in this type of setting would be of additional benefit over the peer-to-peer interaction and sense of community that already exists. It is also unclear which patients would benefit the most from this type of web-based intervention.

Patient appropriateness should be considered, as the results of hypergraphia, as seen in mania, psychosis, and some forms of epilepsy, would probably not be as helpful. The psychiatrist also should be aware that for some patients, writing may represent resistance, and delay progress rather than facilitate it. Ideally, the creative writing should not be the focus of therapy but the springboard from which therapy proceeds.