Writing In Healthcare Settings; Bibliotherapist Or Community Writer? Fiona Place Discusses The Role Of Writing Groups In Mental Healthcare.

Bibliotherapist or Community Writer? Fiona Place (Australia Council funded Writer-in-Residence) examines the use of literature in therapeutic settings Paper presented at the First National Conference/ Workshop

‘The Arts in Health’ Toowoomba Nov 4-6, 1994

Literature in health: creating spaces for change Today there is an increasing interest in the benefits of using art in the field of health-care. This interest is to be welcomed and applauded - the work done by artists within health settings has for too long been dismissed as merely discretionary, or worse still, upsetting. This increased appeal, however, is also creating divisions. Divisions between those who see themselves primarily as artists and those who see themselves primarily as therapists. These divisions are not simply academic. With health organisations increasingly looking to employ artists and the recent introduction of two Masters Degrees in Art Therapy a formal re-structuring of the whole field is taking place. Issues such as the registration of art therapists and the arrangements to be made regarding sources of funding will affect everyone. Questions such as: How should art be used? By whom should it be used? And what training should they have? Will need to be addressed. In the case of literature there is a need for writers to address the issues. Should literature be included within the field of art therapy, it may become increasingly difficult for writers who do not wish to use literature from within an art therapy framework to be recognised and employed by public health-care institutions and organisations. Health-care policy-makers need to be made aware that if art is to provide creative and innovative spaces for change, the structures set in place for its use also need to be broad and diverse. It is therefore crucial there is wide consultation to ensure that artists are not excluded from this debate. Entry points for artists who choose to work within health settings need to be established. The use of art and literature must remain open to artists. With this in mind it would seem appropriate to review the current situation, especially in its relationship to literature. For although the art therapy paradigm makes many valid and important contributions to the ways in which literature is thought about and used within health settings, it is not the sole approach. Other approaches need to be acknowledged. We must work to ensure that the perspectives from writers who choose to work within health settings primarily as writers form part of our foundations for future growth. The current situation In the United States the use of literature within health settings is well established. There, an approach known as bibliotherapy, has been developed. This approach combines the knowledges of

psychology and literature. It focuses on the therapeutic aspects of the reading and writing process and has been developed mainly by health and welfare librarians within the American Library Association. Bibliotherapy regards literature as a therapeutic tool which can be used to encourage and foster insight as well as serve as a useful aid in assisting people to develop skills in problem solving. Literature in this context is seen as a catalyst for therapy. This use of literature has led to bibliotherapists working more like psychotherapists or psychologists rather than writers. According to bibliotherapist Arleen Hynes (1980) bibliotherapists can be further divided into two groups: clinical bibliotherapists and developmental bibliotherapists. ‘Clinical bibliotherapists are those who use literature as a tool with the mentally ill who have a contract for therapy.’ While ‘developmental bibliotherapists are those who use feeling responses to literature to stimulate the growth of normal individuals from children to the elderly.’ In the United Kingdom the field is still at the fledging stage, with librarians and to a lesser extent writers and other allied health professionals developing ideas. The term reading therapy, rather than bibliotherapy, is currently being used and covers a wide range of activities using library resources within therapeutic contexts. According to Mary Howie (1988) reading therapy can be defined as: ‘the use of literature and/or audiøvisual materials, by a trained worker, to facilitate a therapeutic activity, usually a guided discussion, which promotes personal growth for the participant(s).’ Here too, literature is seen as a catalyst, as a tool for the promotion of psychological insight. In Australia the field is not as established as it is in the United States. Here the use of literature has been pioneered by writers and allied health professionals, rather than librarians. As a result there has been little comparison or connection made between the work in Australia and that of bibliotherapists in the United States or reading therapists in the United Kingdom. The area is presently under-resourced, under-valued and yet to be formally recognised. It is not included as a specialisation within the current Master of Arts Therapy programs and is not represented within existing professional organisations for art therapists. Amongst writers, however, many of whom have worked within health settings under the auspices of the Writer-inCommunity Program funded by the Literature Board of the Australia Council; there is much discussion of the term therapy. Many see a need to resist the work they do being labelled bibliotherapy, writing therapy or reading therapy because they believe the term therapy limits the way in which literature is thought about and used within therapeutic communities. There are signs, though, that a similar approach to that taken in the United States is emerging. The proposed curriculum for an Arts in Health Post-Graduate Program in Queensland views art from the health-care paradigm. The course, to be offered to artists and health workers alike, describes art as a therapeutic tool and treatment option. Discussion centres on the need for health workers and artists to be trained from a health-care/therapy-based perspective. While this emphasis is no doubt driven by genuine concerns regarding patients/clients welfare it is also due, in part, to the ‘therapy-bias’ present in institutions and to the current financial arrangements in which anything that is not labelled as ‘therapy’ will find it difficult to attract funding from already stretched health budgets. But what are the effects on the processes of reading and writing if literature is regarded as a therapeutic instrument? And can it automatically be assumed that a therapy-based perspective will be most helpful? Problems with the health-care/therapy-based perspective The use of literature as a tool for therapy has the potential to create several problems. Firstly, an approach which sees itself primarily as therapy introduces a therapeutic structure in which there are often defined roles - therapist and patient/client. While the adoption of this framework can be helpful, adverse effects such as role rigidity may reinforce the identity of the

participant as patient. Writing therapy may come to be viewed as just another variant of psychotherapy. Or worse still, one more institutional demand. Secondly, an approach to literature which sees its primary function as a means of reaching feelings, treats literature as though it is neutral; a knowable and transparent tool. This approach fails to address the complex relationship between reader and text and is unable to provide participants with the space to develop the necessary skills to question and deconstruct texts: to question the implicit values encoded in every text, including their own narratives. Thirdly, an approach which focuses on a text’s ability to suggest solutions or ways of dealing with problems runs the risk of using literature to merely teach certain values. And not create the space for the patient/client to explore and choose their own values. Fourthly, an approach which uses literature to offer psychotherapeutic interpretations may, if too rigidly applied, pre-form the desired response regardless of need. If psychotherapists are encouraged not to interpret excessively or wildly the same needs to be said for a therapist using literature. It can be disturbing and anxiety-provoking to patients to have their needs and feelings brought to their attention before they are ready. A focus on a psychological reading of the text and the feeling responses of the participants runs the risk of blocking the reflective space available to participants and limiting discussion to the psychological paradigm. This appropriation and psychologising of art is, therefore, to be strongly resisted. The moment art is institutionalised and administered from a health-care perspective it will lose its ‘otherness’ and potency to effect change. Other approaches Artists working within health-care settings often employ models from outside the health-care paradigm. They do this for many reasons. Many perceive a need to remain ‘from the outside’ if they are to offer those in a therapeutic community a cultural experience. And to de-medicalise the space in which they find themselves, must work against the dominant health-care paradigm which views people as patients. Their choice of model will depend on many factors; the needs of the community, their own particular skills, the length of the residency and the particular constraints present within the community. Models may also emphasise different priorities and be influenced by a variety of theories including; communication, literary, feminist, oral history, community art, and cultural development. So how does this work out in practice? The following account is based on my experiences as Writer-in-Residence at the Psychiatry Unit, Prince Henry Hospital. This residency was funded by the Writer-in-Community Program/ Literature Board of the Australia Council and it was during this time I faced many of the issues I have outlined. My residency, although supported by various senior medical staff, was seen by the hospital administration as belonging to the ‘too difficult basket’. They were wary of my coming in as a writer and keen to make sure I did not conduct what could be construed as therapy. On the other hand, as time went by and they saw that what I was doing was therapeutic they were thrilled to have me there. And when my contract expiry date loomed were more than happy for it to be extended, but only if the Literature Board of the Australia Council was willing to continue to provide funding. The model I chose to work with was a ‘participatory model’. This meant that patients would not be regarded as patients attending a writing group but rather, as participants engaged in writing and reading groups that would, as far as possible, be directed by their needs. This decision took into account the shortness of my residency and the necessity to work slowly and gently against the many resistances to my working as a writer in a psychiatric setting. It was important to provide participants with access to an activity that was not therapy-based and that would allow them to find their own voice. I also believed there should be a strong cultural component to the residency and set up a library of contemporary Australian literature in my office.

I used these texts in the reading and writing groups and encouraged borrowing by the participants. As it was the first residency of its kind at the hospital and I had limited support any grand-scale projects such as involving both patients and staff in the scripting of a play, or compiling a history of the Psychiatry Unit from the perspectives of both past and present staff and patients, were out of the question. What was possible was to run a twice-weekly writing group open to all patients and a twice-weekly reading group for people with an eating disorder. I also made myself available for individual consultation and acted as a resource person for information about other art and writing groups in the outside community. As the residency progressed I saw my role as providing participants with a cultural activity plus the means by which to access it. This meant that much effort went into working against their beliefs that they could not write or enjoy reading. I therefore decided upon a writerly approach. An approach which focussed on facilitating their search for their own voice.

The Writing Group Following the suggestion of Leston Havens (1978) that the language of investigation and therapy is as important as the matter being investigated or treated, I encouraged group members to look at how language is used to shape us and how we use it to shape others. To facilitate this the group only had one rule - no one was allowed to ask if a story was true or not. This emphasis on writerly concerns grounds discussion in reading and writing rather than personal issues. The emphasis is on how texts are constructed and work at shaping the reader’s response. For many participants, both staff and patients, this can require a lengthy period of adjustment, as discussion groups in therapeutic communities are often concerned with the personal. Initially, participants did find it difficult not to ask personal questions. For example, in a writing group, responses to a participant’s poem may include such comments as: ‘Oh, I didn’t know you felt that way about your mother’ or: ‘You’re so like that, so sad,’ which immediately attribute the contents of the poem to the individual who wrote it. But such comments are to be expected in any writing group and I have found that introducing the rule helps to overcome this problem. At first participants may find it perplexing and difficult to stick to, but once they realise where this leads the group they relax and start to enjoy becoming a writing rather than therapy group. One of the initial exercises I asked participants to do was to write about themselves in the first person but for it all to be lies. I gave them approximately twenty minutes and then asked them to read out what they had written. Later I instructed them to keep to the first person voice of the character they had created and to write about where their character had grown up. This they did exceptionally well. They were able to work backwards, creating the child from the adult. I then asked them to write about the character in the third person from the point of view of a friend or acquaintance of the character. Doing these and similar exercises seemed to allow participants to explore how language shapes experience and in turn how they could apply such questioning to their own narratives. The aim was to shift the person from experiencing themselves as an object to a subject who can speak for themselves. The focus is placed on writing technique, on how they are telling the story. According to Kathy Davis (1986), one frequently heard critique of psychotherapy in feminist circles is that it turns the person’s initial version of their ‘troubles’ into therapy talk. Story telling can avoid this transformation since it doesn’t focus in on ‘troubles’ but gives the voice of illness a means of expression, one which can be de-medicalised and rejoined to the everyday. The work of group members To illustrate these points I would like to share with you some examples from the work of the participants as published in CoastalWritings.

Firstly, I would like to present the work of a seventeen-year-old woman with anorexia. This woman seemed to see only the surface of any concept; there was no detail, no layers. For example she would say nature is nice but be unable to describe what about nature was nice for her. She seemed to find writing difficult but said she enjoyed Writing Group the most out of all the groups and was most impressed with the improvements she noticed in her own work. This is one of the first pieces she wrote. Portrait CoastalWritings No.1 I am thinking and looking very puzzled at what to do. I am touching my forehead in really deep thought, trying to work out where I am in my thoughts at this very moment but finding it hard to try and identify it. I am smelling the mist of the ocean and all the beautiful nature that surrounds me at the time of all my thoughts and puzzlement. I experience and take in all the noises that surround me. I taste the sweetness of the food I am eating and feel guilty and scared.

This is a piece she wrote six weeks later. Fantasy CoastalWritings No.2 it would be very pink to be happy and enjoy life to the fullest and it would be gorgeously red like the sunlight to be able to wake up and not have a worry in the world and just take life and the days as they come like sparkling stars in the nightlight. . .

She speaks as a subject, using language figuratively. She is centred and in control of the piece. This is another poem she wrote. Slowly CoastalWritings No. 2 Slowly the clock ticks on Slowly the plane takes off Slowly the doctor explains things Slowly the rain comes down Slowly the cleaner cleans Slowly write Slowly move down the aisle Slowly take in things that are said Slowly pick the radio station

In this poem she describes the world in more detail and how she sees it. Time enters the process of meaning and a sense of order, a narrative begins to emerge. She describes how slowly everything seems to be happening but towards the end of the poem the last two lines, Slowly take in things that are said - Slowly pick the radio station, seem to suggest she is beginning to engage with the world. The next poem shows a shift to less concrete thinking and the emergence of a distinctive voice. She was particularly impressed by her ability to write the following poem which required several reworkings. Object CoastalWritings No.3 this square object is coloured

and rids bad thoughts, a sedative relaxing me diagonally straight (and) sideways

The next piece of work is from a forty year old woman who has had numerous admissions for periods of both mania and depression and attended the group as a day patient. She has always written, is exceptionally creative and has a good grasp of narrative structure. Here is an example of her work and how writing can provide the space to create multiple subject positions. In the Sea CoastalWritings No.2 Fish Oh my, you must be my parents, hey come back, don’t leave me as you swim away, oops what was that, gee he looks nice enough to be with. What a big wide wavy place this is, I feel lost, - help somebody save me. Oh well I’ll just tag along with all these other colourful creatures. Shark Gee I’m hungry, there’s plenty of nice fish for me to eat, hey just a minute there’s lots of bodies at the beach today (mm yum) blood , where’s that coming from, oh there’s a boat upside down, a leg or even an arm. If I’m fast enough I’ll make it, oh just missed out. Fred beat me to it, he swims faster than me... Oh well I’ll just have to settle for - anything goes. Photographer Hi, I’m doing just what I like, deep-water photography. Some days it’s as colourful as you can imagine, there’s lots of caves, fish of all types and an occasional shipwreck. I always carry my spear gun with me, just in case of sharks. The fish are quite tame, they even eat out of my hand, but one day I nearly lost my whole arm when a white pointer came from out of a cave. I had to be quick. The fish are slimy little creatures but very pretty. I like watching the turtles, octopus, sting ray and all the creatures in the sea.

She has presented the different voices of the fish, shark and photographer. This type of exercise demonstrates the way in which any situation does not exist independently from the way it is viewed. Who is viewing will always alter what is seen to be happening. It also shows how each of us can place ourselves in many different subject positions and see things from different points of view. The following is a similar type exercise and was written by a young man in his twenties with schizophrenia. Shopping CoastalWritings No. 1 The Child My hand reaches for the toys and for the lollies too and I wish I could have a bike and surf board to ride the streets and waves at the beach. The Trolley I’m pushed here and there and everywhere and my broken wheels are hard to manage. I’m lost and wait for someone who will not be late to return me to the line. The Check-out Person I stand wait and anticipate.

This man took great pride in being able to write and read his poems out loud at our reading evening. The attitude towards him by both staff and other patients changed dramatically when it was discovered he did have a voice and an ability to write. The following work is from a seventy one year old woman who was admitted with major depression. Although failing to respond to orthodox treatments she found writing to be of great assistance. Previously she would not accept any of her physical pain was related to her feeling depressed but after starting Writing Group agreed that 80% of her pain was depression related. Possibly she enjoyed herself so much she connected feeling good with no pain but I think it more likely it was this plus her new found experience of being able to describe how she felt in her own words. At the first class when asked to write about herself but for it all to be lies she created the character Brenda and then seemed to work out many of her conflicts and desires through this character who she described as wicked and out of control. Ode to Brenda CoastalWritings No.3 Really I don’t know where to start. I never tell a lie, well maybe little white ones. The sisters don’t care a fig about me and the male sisters in Acute, well, need I say more? Every patient here is as sane as a Judge. We have no therapy, polluted Sydney beaches are pure compared to the pool at Prince Henry. The food is porridge and more porridge and it’s wicked the way they make you feel like Oliver Twist when you ask for more. Really I think the cleaning staff should run the place and the doctors and nurses run the kitchen. Oh, but I hate to tell lies and I’m doing it again. Notice left on the door of the nurse’s office Where are the nurses? If I were Brenda I’d say? Where are the clowns? But I’m not Brenda. Brenda’s Last Request CoastalWritings No.2 Please don’t talk about me when I’m gone. Don’t draw the curtain. You will enjoy Brenda from now on. Brenda is writing her last epitaph. Thank goodness I hear you say. Do I hear you laugh? I realise I’m growing old. Silver hair amongst the gold. Before you draw the final curtain. We will sing, I promise it won’t be long. I close my eyes you draw the curtain. We know for certain any dream will do. When I awake he will be waiting and celebrating. Any dream will do.

The Reading Group The aim of the Reading Group was to introduce those with an eating disorder to a wide variety of Australian poetry and fiction for discussion. The discussion began by examining the texts from a

writerly and cultural perspective and on the initiation of the participants focussed on the notions of metaphor and multiple meaning. The participants became interested in their desire for the poems and short stories to have one meaning and for that meaning to be literal and static. This discovery, which they felt paralleled their thoughts on food and weight interested them and they used the Reading Group as a point of entry to explore the notion of multiple meaning. They were fascinated that each of them read a story differently. They were equally surprised how their own desire for categorical answers influenced how they read. And slowly came to realise how the ways in which they were currently storying their lives were extremely restrictive. They were also keenly interested in reading outside what they usually would have considered ‘their kind of thing’. Many had not read anything since they were at school and didn’t know how to choose books, where to find them or how to continue an interest in books by themselves. They were keen to keep reading once they left hospital and we discussed ways in which they might do this. There were certain differences between the Writing Groups and Reading Groups I ran at Prince Henry and other creative writing courses. Firstly, people could join at any time and choose to attend one week and not the next. This had some drawbacks, but overall seemed to suit the needs of the community best. Secondly, most group members seemed to prefer to work within Writing Group rather than do work outside of it and bring it along for discussion as is often done in writing groups. This is not to say they did not write outside of group but since only some members manage to do so and people’s level of interest and ability to concentrate seemed to vary week to week it seemed best to spend the hour and a half doing exercises, sharing them and examining other texts. The work of the group members was published in CoastalWritings which came out every six weeks and was distributed amongst staff and patients.

The benefits of a writerly approach This approach works against the status of patient, giving participants an opportunity to be something else other than patient. They are introduced to a cultural activity, in this case writing and reading, which they can continue once they leave the hospital. They also benefit from the reflective textual space opened by the groups. This space allows participants to challenge the narratives the institution has imposed on their lives. They can, either publicly or privately, start questioning the ways in which their life experiences are storied. For example, the diagnosis of anorexia nervosa and their own ‘I’m fat, I need to lose weight’ story can be explored for what it is not telling, for the ways in which it hides/distorts and changes their real personal experience. Participants are empowered to find their own voice and create new meanings for themselves. Many participants seem to experience themselves primarily as objects. They often talk about themselves rather than as themselves. For example, a woman with anorexia, who when I asked how she was, would often frame her reply in terms of: well, the doctor said this or the doctor said that, or she herself would use psychological jargon to describe how she felt. She did not seem able to find her own voice, to sift through the different ways of describing experience and choose what felt right for her. This is the case for many participants in psychiatric settings. Their dominant life narrative is the story of their problem rather than how they experience life. Emotional expression is often missing or presented in psychological jargon. For example, in the case of this woman, the story of her life was the story of her eating problem. She would relate the circumstances of her many admissions in such a flippant, detached manner that it was difficult for others to connect with her in a meaningful way. Unfortunately, this sterile repetitive recitation is often exacerbated within a psychiatric setting. The use of psychological and institutional jargon de-personalising a person’s life narrative even further.

This woman’s experience may be contrasted with those people who experience themselves primarily as subjects. They are able to contend with the conflicting discourses which continually try to shape them and still maintain their own voice. There is robustness. They are able to create various and often quite different narratives about themselves and their lives. This capacity to experience ourselves as subjects means we need to be able to observe ourselves, to be both participant and observer, subject and object. For example, if someone has a headache they need to be able to differentiate between having head pain and the often multi-layered experience of headache. The treatment for head pain is aspirin, but the individual with a headache may come to see it as the best way they know to express their distress about an unexpected loss or conflictual relationship. If someone cannot experience the difference between participant and observer there is no space across which such connections can be made. The non-therapy approach, the textual grounding helps in this search for meaning. It limits the space for psychologising while opening up the space for reflection and questioning in a nonthreatening manner which is unlikely to be intrusive or damaging. It also allows participants to come into contact with a wide selection of contemporary Australian poetry and fiction and see how others, too, are struggling with the search for meaning. Sometimes, however, participants will write something which either directly or indirectly taps into their emotional state and when it comes to sharing it with the group be overcome by the intensity of their feelings. When this happens I believe it is important to handle the situation with sensitivity, to acknowledge to the group that writing/reading can sometimes bring painful feelings into awareness and more importantly that those feelings are dealt with both sensitively and appropriately. Summary and conclusions The impending descent upon the arts by the health-care curriculum writers and policy-makers demands a strong response - without it the current approach with its ‘feeling responses’ to literature will be adopted by the health-care institutions and writers wishing to work as writers will be excluded. It is time the role of literary theory and community arts theory are promoted as equally viable. That we see it as essential to keep open a variety of approaches. It is equally important that writers be allowed to choose their own approach. It is not a matter of pitting the health-care/art therapy model against the community arts model. Writers must be free to create approaches that work the community in which they are employed. And each community requires a different approach. For example, were I to work in an oncology unit I would not necessarily use the same approach I used in the psychiatry unit. Needless to say, not all psychiatry units are alike either. If writers are to be effective they need to be flexible and be allowed to choose the approach they see as meeting the needs of the community. Appropriate models should not be forced upon them. We must work towards creating a flexible structure and an acceptance of cultural diversity. The role of art within health is a complex issue: the role of the artist within in a health setting - an exciting challenge about which informed, intelligent discussion is needed. The current trend to therapise art could, in the long term, leave health-care policy-makers wondering why they ever bothered in the first place. Literature needs writers. And their experience and knowledge need to be valued and shared with those in the health profession. In this way the use of literature within therapeutic settings can continue to grow and develop and is less likely to become limited in its approach.

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References

Davis K. (1986). The process of problem re-formulation in psychotherapy. Sociology of Health & Illness, 8, 44-74. Havens L. (1978). Explorations in the Uses of Language in Psychotherapy: Simple Empathetic Statements. Psychiatry, 41, 336-345. Howie, M. (1988). Reading therapy and the social worker: In Clarke JM and Bostle E. (Eds.) Reading Therapy. London: Library Association Publishing. Hynes, H. M. (1980). The Goals of Bibliotherapy. The Arts in Psychotherapy, 7, 35-41