Can Creative Writing, as an Add-on to Treatment for Alcohol Use Disorder, Support Rehabilitation?

ABSTRACT

Creative writing may help patients find new powers in the acts of making art and expanding horizons beyond illness, including addiction. The aim of the present pilot study was to introduce creative writing workshops to alcohol use disorder (AUD) patients and investigate self-perceived rehabilitating impact, improvement in quality of life, and executive functions. The study was conducted in a mixed methods design; primarily semi-structured group and individual interviews as well as participant observation, supplemented by a small evaluation questionnaire at baseline and follow-up at the end of exposure. The patients had experienced the workshop as having influenced their lives in a positive direction, impacted by doing creative writing, sharing and receiving feedback, and the community of the group. The patients perceived both advantages and disadvantages about discussing alcohol in the workshop. The patients experienced an increase in quality of life from the beginning to the end of the workshop. There could be a need for creative writing workshops as add-ons to ordinary AUD treatment. In such an offer, creative writing might function as a means to improve patient rehabilitation, quality of life, and executive functions.

KEYWORDS:

• Alcohol use disorder
• treatment
• creative writing
• mixed methods
• qualitative

Introduction

The relationship between art and health has been at the center of human interest from the beginning of recorded history. However, it is only in recent years that systematic and controlled studies have examined the therapeutic effects and benefits of the arts, including creative and expressive writing. A review from 2010 of current research literature considering the connection between art and health states that expressive writing can contribute with many aspects of physiological and psycho-social conditions associated with improved health status. According to the review, several clinical studies have shown that relative to control group participants, individuals who have written about their own traumatic experiences exhibit statistically significant improvements in various measures of physical health, reductions in visits to physicians, and better immune system functioning (Stuckey & Nobel, 2010).

James W. Pennebaker is considered the leading researcher on the power of writing for therapeutic purposes. He argues that when people articulate their feelings and thoughts about personally upsetting experiences in language, their physical and mental health often improve (Pennebaker, 2004). Pennebaker and Cindy K. Chung have published a review of the research literature considering the connections between expressive writing (referring to attempts to write factual reports of one’s own personal experiences, as one might in a diary or journal) and health which concludes that expressive writing among other things promotes sleep, enhanced immune function, and reduced alcohol consumption (Pennebaker & Chung, 2012). In a Scandinavian context, one study indicates that expressive writing produces a release of cognitive, emotional, and relational tension in the participants; it may, for example, be effective in reducing breast cancer patients’ frequency of visits to a physician. Expressive writing may also have beneficial effects on somatic factors and reduce pain symptoms (Gripsrud et al., 2016).

Another recent review provides evidence that narrative medicine’s method of creative writing is a useful tool to assess the patients’ experience of illness and a powerful instrument for decreasing pain and increasing well-being related to illness, for being more confident, active and cooperative in respect to the illness, having a less stressful response, and decreasing feelings of alienation (Fioretti et al., 2016). The concept of creative writing as imaginatively discovery, central to the intervention evaluated in this article, is inspired by Rita Charon and her colleagues from the program in narrative medicine at Columbia University and the long tradition of teaching creative writing in America (Charon, 2006). Creative writing goes beyond the writer’s own personal experience to imagine events and create situations that, although not ”true”, can help the writer to discover unsaid wishes, dreams, hopes, and goals (Charon, 2016). Writing creatively is, at root, an externalizing and imaginative activity different from expressive writing; it is a method by which the participants learn to perceive the world and acknowledge their life through aesthetic forms (Hermann, 2017). Creative writing may help the writer to find new powers in the acts of making art and may expand the writer’s horizons beyond the restricted realms of a series of illnesses, including addiction (Hansen, Zwisler, Laursen, & Rasmussen, Forthcoming in special issue ”Patient narratives”, fall 2019).

Finally, a review of the use of creative writing interventions in treatment for substance use disorder (SUD) concludes that despite limited research in this particular area, the activities involved in writing appear to be a viable treatment intervention that can not only lead to decreased drinking intentions, but can also lead to improvements in depression, anxiety, trauma symptoms, and physical health in individuals with substance abuse issues (Snead, Pakstis, Evans, & Nelson, 2015). The same study found that treatment sessions, involving creative writing, have been linked to improvements in self-confidence and self-esteem, social skills, social and emotional self-expression and self-disclosure, coping, self-awareness, and trust in this population. If clients have not previously had experience with creative writing, leisure skill development may also occur.

Yet, despite the growing number of promising studies, neither expressive nor creative writing is a panacea. The overall effect size of writing in all previous studies is modest at best. One still does not know for whom it works best, when it should be used, or when other techniques should be used in its place.

Alcohol use disorder (AUD) produces a wide range of executive dysfunctions, including within the areas of attention and concentration, information processing, and mental flexibility. Studies have reported that recovery of these executive functions may require, not only control of or long-term abstinence from alcohol, but that further interventions may be needed. As such an intervention, creative writing is hypothesized to improve executive dysfunctions.

In Denmark, the responsibility for offering treatment for AUD is placed in the municipalities by law (The Danish Parliament, 2016). Currently, there is no tradition for broadening the focus for the treatment of AUD by offering add-on treatment, e.g., focusing on overall recovery, improvement of mental health, improvement of executive dysfunction, or physical health.

In 2017, however, a feasibility study on creative writing (Hellum, Jensen, & Nielsen, 2017) was conducted in a specialized harm reduction unit in a public alcohol treatment clinic. The aim of the feasibility study was to test the feasibility of creative writing workshops among a particular group of patients suffering from chronic alcohol dependence. In the feasibility study, six of the chronic patients decided to participate in the creative writing workshop for 2 h every week for 6 weeks. The feasibility study indicated that the patients were able and willing to participate and that training in creative writing may increase patients’ self-confidence and the unity in a group. The participating patients also described that due to the creative workshop, they felt that they were given more new nuances in life, had received stimulation of the brain, and got zest for life. Finally, both therapists and participating patients experienced improvement in the relations between them following the creative writing workshops (Hellum et al., 2017).

Based on the experiences from the feasibility study in 2017, the research group decided to conduct this present pilot study among a broader group of patients, prior to a planned future up-scaling of the project. The aim of the present pilot study was to introduce creative writing workshops to a broader group of patients, seeking treatment for AUD, and investigate: 1) the self-perceived rehabilitating impact of participation in the creative writing and reading exercises; 2) whether a notable improvement in quality of life can be seen among patients, not only during but also a month after the workshop; and 3) whether it may be hypothesized that executive functions among the patients have improved.

Methods

Design

The present pilot study was conducted in a mixed methods design (Creswell & Plano Clark, 2011); primarily semi-structured group and individual interviews as well as participant observation, supplemented by a small evaluation questionnaire at baseline and follow-up at the end of exposure.

Setting

The creative writing workshop in the present pilot study was an open offer to all patients attending the public outpatient alcohol treatment clinic in Odense, Denmark.

At the clinic, treatment for AUD is offered by a multidisciplinary team of nurses, social workers, and psychiatrists. At the beginning of the treatment course, patients are offered detoxification, if needed. During the acute treatment phase, the patients are offered Motivational Interviewing (Miller & Rollnick, 2013) in addition to pharmacological treatment. When the withdrawal symptoms are treated, the patients are offered a structured assessment interview and an individual treatment course, consisting of either cognitive behavioral therapy, family therapy, contract treatment, or supportive consultations. The therapy is performed during 1-h weekly or bi-weekly sessions. Every 3 months, the patient undergoes status sessions, where the treatment course is evaluated. The planned duration of treatment is 3 months and prolonged thereafter if needed. The majority of treatment courses last 3–6 months after which the majority of patients conclude the treatment.

However, a small group is referred to the harm reduction unit. In this unit, the most chronic patients are offered long-term intensive outpatient treatment as a means to reduce the number of relapses. The harm reduction treatment lasts for one to two years and consists of one to four flexible meetings at the clinic every week; additionally, access to social activities.

Recruitment

Prior to the creative writing workshop, the researchers met with the therapists at the clinic to inform the staff about the workshop. During the 2 weeks following this meeting, the therapists informed their patients about the possibility of participating in the workshop. Information about the workshop was also posted in the waiting room of the clinic. The patients signed up for the workshop at the administration office.

Course of the creative writing workshop

The workshop lasted 6 weeks with one session per week; each session lasted 2 h from 10 am to 12 noon. One half-hour before every session, all participants were offered breakfast. Two authors, with prior experience in teaching creative writing, taught the patients how to write creatively. The content of the workshop can be seen in Table 1. The first three sessions were led by author Trisse Gejl and the last three sessions by author Pablo Llambías. During all sessions, a therapist was present to handle possible situations where the patients needed guidance from a therapeutically trained professional. In the first and last session, two researchers were present; in the rest of the sessions, only one researcher, at a time, was present. After each session, the authors, the therapist, and the researchers discussed impressions from the session and the agenda for the next session.

Table 1. Content of the creative writing workshop.

Session 1	Exercise 1: Two dice were rolled. The participants were asked to write a small story describing an episode from their childhood, starting with the number of eyes seen on the dice, for instance: “When I was ‘the number of eyes on the dice’ years old, I … ” The story was supposed to be in I-form and written in past tense. The participants read their stories out loud if they wanted to. Exercise 2: The dice were rolled again, and this time the participants were asked to write another story in he/she form and present tense: “He/she is ‘the number of eyes on the dice’ years old, and … ” The participants were asked to add senses to the story in order to show what happened rather than just describing it to the reader/listener. The stories were read out loud. Exercise 3: The participants were asked to include all five senses and paint a scenery with words which gave the reader/listener a feeling of the story.
Session 2	The author, Trisse Gejl, read out loud from one of her own novels as an example of how to describe a landscape by using all senses. She then read some poems out loud written by other authors about addiction and psychiatric illness. Exercise 1: The participants were asked to write a story from the dentist’s waiting room. A note with a mood was drawn from a box and applied to the story. The stories were read out loud and the other participants had to guess the mood. Exercise 2: Another mood was drawn from the box and the participants were asked to write the same story but in another mood. Again, the other participants had to guess the mood.
Session 3	The author began by presenting the concepts of writing they had used in the first two sessions. She then read a short piece of a text by a poet. Exercise 1: Free writing for eight minutes about the morning. Exercise 2: Free writing for eight minutes about the ocean. Exercise 3: The two texts were read out loud and then used for a cut-up exercise (Jones, 1965) where they were cut up in clauses or words and used to make a new text. The cut-up texts were read out loud and the session ended by the author reading out loud a cut-up text she had made herself years ago.
Session 4	The fourth session began with the other author, Pablo Llambías, reading out loud a short story he was currently writing. Exercise 1: The participants were asked to write about their childhood kitchen. The stories were read out loud. Exercise 2: Free writing. Exercise 3: A word from the free writing should be used as the title for another free writing. Exercise 4: The participants were asked to write about a room they liked to be in. The stories were read out loud.
Session 5	Exercise 1: Free writing for eight minutes without any topic. Reading the text out loud was optional. The author had some comments on writing techniques to the texts. Then the author read from a poem of another author. He spent some time explaining the poem and discussing the text with the participants. Exercise 2: Inspired by the techniques used in the poem, each participant had to write eight words they found beautiful and then write a little text with all eight words included. The 8 words were read out loud and the texts were read out loud and discussed. Exercise 3: A chain-text where each participant started by writing a sentence containing a person, a place, and an action. The text was then passed on to the next person, who could only see the latest sentence. When the texts had circulated the table, they were read out loud and discussed.
Session 6	Exercise 1: A free-writing exercise for eight minutes. Reading the texts out loud was optional and some of the texts were discussed. Exercise 2: The participants were asked to find a word/element in the previous text to write about in this text. The participants were given eight minutes to describe the word or element and its surroundings in detail. The texts were read out loud and discussed. Exercise 3: The participants were asked to write six words they found beautiful on small pieces of paper. The papers were folded and placed in a bowl and all participants had to draw six new pieces of papers and write a text from the words. The texts were read out loud and discussed.

Data

Data for the present pilot study stem from different quantitative and qualitative sources.

At the beginning and the end of the course, the researchers collected questionnaire data filled out by the patients. The questionnaires were developed for this study with questions relevant for the research question. The baseline questionnaire contained questions about sociodemographic data, alcohol use, experiences with writing, and quality of life. To measure quality of life, we used selected questions from the questionnaire WHOQOL-BREF (World Health Organization, 2019). The follow-up questionnaire contained questions about alcohol use and quality of life since baseline.

Immediately after the sixth and last session, an unstructured group interview was conducted with six patients and the participating therapist. The interview was about how the patients had experienced attending the creative writing workshop. The interview lasted for about 20 min and was audio recorded and transcribed.

Approximately 1 month after the last session, the six patients and the therapist were invited to participate in individual semi-structured interviews. Two of the researchers interviewed three patients each and the therapists together. The interview guides for the individual interviews were developed by the researchers, based on findings from participant observations and the group interview. The interviews were about how the patients and the therapist had experienced attending the creative writing workshop. The interviews lasted about 20–30 min, except one which was about an hour. The interviews were audio recorded and transcribed.

Qualitative analysis

The qualitative data from the group interview and the individual semi-structured interviews were analyzed by the means of a General Inductive Approach (GIA) (Thomas, 2006). GIA is often used within social, health, and evaluation areas, since it offers a straightforward approach to derive findings linked to evaluation questions. GIA is a generic method, not guided by explicit philosophical assumptions; findings are to emerge inductively from the themes in the raw data, without restraints imposed by structured methodologies.

Two of the researchers performed the inductive qualitative analysis separately. The interviews were read multiple times in detail to gain an understanding of the meanings inherent in the text. Through interpretation of raw data, categories were coded into a framework that summarized the raw data and conveyed the key themes. The themes were then compared. At last the category system was revised and refined by searching for sub-topics and adding essential quotations. One text segment may have been coded into more than one category and some may not have been coded at all, if not relevant to the objectives.

Ethics

The pilot study is notified to the Danish Data Protecting Agency, notification number 2015-57-0008, and file number 18/10271. Since the pilot study is based on questionnaires and interviews, it is not notifiable to the Regional Committees on Health Research Ethics for Southern Denmark but conducted in concurrence with ethical standards. After receiving oral and written information about the project, the patients signed consent forms for participation.

Results

Baseline sample characteristics

A total of 10 patients signed up for the workshop. At the first session, two patients decided to withdraw, since they felt the contents of the workshop were unsuitable for them. One patient only showed up for the first session but failed to appear for the rest. Later, an additional patient decided to withdraw. Ultimately, the workshop consisted of six patients; in each session, between four and six patients attended. Their reasons for entering the workshop varied. One patient wished to get a new tool to divert her thoughts; another just found it exciting and was used to write when she experienced racing thoughts. A couple of the patients felt it would be interesting to try it out, they were curious, and had no further expectations for the workshop. Table 2 shows baseline sample characteristics for the six patients.

Table 2. Baseline sample characteristics.

	Mean (SD)	%
Sex (female)		50
Age	57
Civil status, single (yes)		100^a
Education, continuing/higher (yes)		66.66
Source of income, salary (yes)		0
Years of alcohol overuse	23.50
Duration of present alcohol treatment course, months	7.5^b
Number of previous treatment courses for alcohol use disorder	3.20^b
Abstinent the past month (yes)		100
Used to writing (yes)		50

^aMissing information: three patients.

^bBased on five replies.

Qualitative findings

The qualitative data analysis led to an inductive construction of three categories; one of them with three subthemes, presented in Table 3 and described below. The categories and subthemes entail descriptions of patient and therapist perceptions of and perspectives on attending the workshop.

Table 3. Qualitative findings.

Categories:	Subthemes:
Creative writing workshop as rehabilitating factor and in relation to quality of life:	The impact of creative writing
	The impact of sharing and feedback
	The impact of the group
Alcohol as a theme in the creative writing workshop
Organization of the creative writing workshop

Creative writing workshop as rehabilitating factor and in relation to quality of life

All participating patients felt that attending the workshop had a positive influence on their lives. One patient would not have participated had he known more about the contents. However, since he had signed up for the workshop, he felt obliged to participate, and did experience something valuable from it.

The positive impact described by the patients covered a range of factors. One felt influenced because he had used his imagination and had his thoughts diverted. Another described how she felt the workshop had improved her language and imagination as well as brought an insight into herself. She explained that it had enriched her life with an ease and a way to surpass the negative by processing and diverting negative thoughts: ”the mere experience of being there, being together, coming there and the writing processes and the feedback and everything, well, I think it has all been uplifting, in that way it has done something positive for me” (Patient 3). This experience was rather similar to the experience of another patient who described how she had learned something about herself during the workshop. The words and assignments presented during the workshop had evoked thoughts and led her to experience both happy and sad feelings, making her reconnect with them. Because of the writing and the group she had changed into a happier state of mind, thinking that life is good: “I think that I have gained a more positive perspective on life by attending the workshop – it might also be because of the fine weather (laughing) but I think it has enriched my life (…) the workshop has affected me, I have gotten a lot of new ideas and become more open towards others, I think” (Patient 6).

The therapist who participated in the workshop also felt it had been very enriching in itself to attend the workshop as such, but also in her role as a therapist, because she had seen other sides, nuances, strengths, and resources in the patients, compared to what she saw during the treatment sessions. For example, one patient had surprised her with a richness of details and brilliant expression of thoughts and feelings in what turned out to be his own writing style; an aspect she had not previously recognized in the patient. The therapist also noticed how another patient, who often seemed very insecure and fragile in therapy, had found his own spectacular writing style in the workshop which expressed longing, love, and coherence.

The impact of creative writing

We observed that the patients took an active part in the workshop and seemed to work concentrated with the assignments. They found writing an inspiring activity; one explained that the workshop had given different inputs on writing, others simply found the writing workshops fun and joyful. None of the patients had felt pressured to performing the assignments, but since they were allowed to solve the tasks with the abilities they had, the exercises ended up being only as difficult as they had let them be. One patient noticed that the assignments were educational with respect to learning how to write detailed descriptions using senses; the play with different wordings had been inspiring for him. Another patient explained: “I have been able to use some parts of the training, and other parts I have not. I make that distinction myself, but I think it has been positive to participate and I have gained insight into how you can make things, write things, and open up, express yourself, and new techniques” (Patient 2).

The patients appreciated solving the writing exercises in common. One patient had in particular noticed the many different stories he had heard during the workshop. Introduction to different writing styles by well-known authors had made it additionally fun for him to attend the workshop. Another patient described it as an eye-opener to see the many different perspectives on imagination, and how this had given him good insight into different expression styles. Yet another patient felt that it had been very enriching for the group that they could concentrate on the same activity and explained how writing in particular enrich: “I think it was good that we were so different in the group, I think that was fine (…) the things we wrote about were widely different (…) I think it meant a lot to see other people’s life perspectives” (Patient 6).

After the workshop, the three women had continued writing, using elements from the workshop. One had, to a greater extent than before, used her senses to enrichen the text when writing on her blog, while another had used ideas and inspiration from the workshop when she was performing daily writing about her feelings or other things. She had realized that it was helpful for her to write down why she was happy or sad, in relation to both alcohol and other issues. One felt that through attending the workshop she had been introduced to a tool that she would not have thought of otherwise. Following the workshop, she began to write down things for herself in a little book, e.g., if she was home alone, felt lonely and craving for alcohol, and needed to convince herself to get out of the house. She even felt that the writing helped her avoid drinking, i.e., by jotting down feelings about pros and cons for buying a bottle of wine. She described how writing became a tool to let go of negative feelings and letting positive reinforcing feelings grow, creating a helpful distance for her: “then I get it out of my system, and I can think more logically, because I am rid of the feeling (…) then I can think much more logically and reasonably, and this is what I have to use the workshop for” (Patient 3).

At the time of the individual interviews, none of the men had yet returned to using specific elements from the workshop. However, one of them argued that the creativity from the workshop was transferred into his everyday life, e.g. when he was using craftsmanship to solve a problem on his house, and another described how the participation in the creative writing workshop had added to his experience when he was reading novels, in particular increasing his attention to details.

The therapist noticed, in particular, how the workshop facilitated a firm structure. Writing became an eye-opener for her; during the therapy sessions, in general, she had often noted how patients deselected homework that implied writing, because they felt a lack of writing skills, felt stressed by it, felt better verbally, etc. In the creative writing workshop, however, they actually participated, even though not many were used to writing. The assignments meant writing in a different way, leading the patients to shoving to feelings and emotions: “besides what it has given these patients, where we look into different experiences, feelings, memories with focus on the pleasant, the nice, the beautiful, when I see, what has come from that, and all the thoughts these people have been through, when I see that, this writing as a tool, with the right steering, you can steer out of other roads some other place in some therapeutic way, where you, with accomplished skill of course, would be able to reach some of that which could be hard”.

The impact of sharing and feedback

The patients were excited about sharing the stories that they had written; one patient described how the other patients had been open towards him and how they quickly had become close. The feeling of acceptance had made an impact: “the reason why it was so easy for me was that the others were so open (…) I think that is why it has been so easy for me, it was not embarrassing for me to share what I had written, on the contrary, it was very easy” (Patient 4). Another patient described how she had only shared if and when she felt like it. Yet another described how she had become more and more willing to share during the workshop, and how it had been a process towards feeling more and more confident. The therapist had not experienced any difficulties balancing sharing her private and personal stories into her professional work.

The patients appreciated the feedback they had both given to and received from each other and from the authors. One patient explained that even though the authors had very different response styles, he felt recognized by both which made him want to come back for the next sessions. Another patient had experienced the authors’ feedback as very positive and wondering towards the used writing techniques (e.g., in a description, which senses used, etc.) which had been very uplifting. Even though she had had bad experiences during her school years, the feedback from the authors provided her with the will to keep writing: “I think it has provided me with the courage to (…) I realized that I actually was good at writing (…) when you experience it this way then it gives you self-confidence and self-esteem” (Patient 3). The therapist felt that the two authors’ teaching styles complemented each other well with regards to the patients. The first author’s feedback was given with lightness and acknowledgment of the patients’ writing. The second author’s feedback was reflecting and commenting on the patients’ writing style.

The impact of the group

We observed that, during the breakfast and breaks in the workshop, the patients conversed about a wide range of subjects. The patients acknowledged the social element of the workshop, being together in the group, and meeting the same people every week. They felt they had gained from the social element in the workshop because they had left their home, attended the sessions, met other people, talked to the other patients; thus, gotten to know one another.

The diversity of the group was also acknowledged. The patients liked that they were different persons as it offered a possibility to talk about experiences with alcohol as well as listen to and learn from each other. One patient noticed how being in the writing process together, hearing about other patients’ backgrounds and their thoughts and stories had made an impact: “alcohol is rough on people (…) it hits high and low” (Patient 1). Although alcohol was not a topic in the writing assignments, knowing that all patients shared a history of alcohol problems added to the coherence of the group from the beginning. Having alcohol dependence in common was said to create an understanding for each other causing them to connect a lot easier and sooner than they had expected: “well I think that everybody was respectively easy to talk with even though we came from different layers (…) everybody was accepted (…) I think that was great (…) I have never been good at getting close to people I do not know, but it was easy with them (…) I felt treated like an equal” (Patient 4).

The therapist, who participated in the creative writing workshop, even noticed: “That coherence, I mean it is just, it is worth gold, and that we find each other even though we are so very different as we are, then we can do something together, and I think that is amazing”. It was her experience that the set-up in the workshop, where everyone shared their stories, made no one feel marginalized: “some of our patients, they feel much stigmatized and here something like this is certainly contributing to punctuating this”.

Alcohol as a theme in the creative writing workshop

In the first session, the patients all mentioned their challenges with alcohol when they presented themselves to the group. Later, during the actual workshop sessions, however, the patients hardly talked about alcohol at all. One patient wrote about alcohol in the exercises but did not share any of those thoughts with the others. Overall, the patients appreciated that the workshop was not about alcohol per se, because they felt that it could get very tiresome to talk and hear about alcohol all the time. One patient even noted that he was happy to have his thoughts diverted from alcohol, since it was so prominent in the rest of his life: “I actually think it has been very nice because it can get very tiresome to talk about it all the time, it is nice to have your mind distracted, like when reading a book” (Patient 1).

Some saw both advantages and disadvantages about not having alcohol as a theme in a workshop. One patient explained how she had expected the workshop to be a process to writing oneself out of a crisis in relation to alcohol since the workshop was held in the clinic and looked forward to that. During the workshop, however, she realized that it had been liberating to focus on the writing and not the alcohol, albeit still safe since all patients knew that the whole group suffered from alcohol problems: “it was fine that the workshop was not necessarily about alcohol because you can also dwell on a crisis or alcohol problem resulting in it being the only issue, in that way I think it has been nice that it was not the theme” (Patient 3).

One patient was directly disappointed that alcohol was not in focus of the workshop. She had also expected the authors themselves to have had challenges with alcohol. The therapist had experienced the workshop as an adequate add-on to the AUD treatment for now. She had experienced neutral themes, patients could relate to and choose freely from, as a good starting point from where they could grow, have fun and realize that they can write even though they did not think so to begin with.

Organization of the creative writing workshop

All patients were satisfied with the organization of the workshop. The number of patients was considered adequate; between 8 and 12, dependent on the available amount of time allowing everyone to read their stories out loud and receive feedback (and not have too many stories to relate to). Most of the patients would have liked more (10–12) and longer (3–4 h) sessions, allowing them to write more. Contrary to the patients, the therapist thought that the timeframe had been sufficient or maybe 30–60 min too short, but also emphasized the importance of a longer course to generate a sense of community. The patients were excited about the facilitators being two different, professional authors, because this gave insight in diverse ways of teaching and writing. It was seen as an advantage that the authors were professional writers, experienced and skilled within writing, enabling all the patients to listen and take part in the workshop. The therapist emphasized the importance of giving choices during an exercise and not only encourage patients’ stories, say, in a room where childhood memories might not be utter bliss.

Follow-up on alcohol use and quality of life

Through the 6 weeks where the workshop took place, all six patients were abstinent.

Figure 1 shows the mean measures on quality of life at baseline and at the end of the workshop. The patients scored more positively on quality of life, frequency of negative feelings, capability of expressing oneself orally and in writing, satisfaction with one’s health, enjoyment of life, and attendance to hobbies after the workshop, compared to baseline. No change was seen in meaningfulness of life. A slight decline was seen on capability of focusing (missing information from one patient).

Figure 1. Quality of life. Mean measures at baseline and follow-up^a.

^a Based on six replies to the baseline and follow-up questionnaire.^b On a Likert scale from 1 through 5 (very poor, poor, neither good or bad, quite good, very good).^c Within the last 2 weeks and on a scale from 1 through 5 (always, quite often, on a regular basis, not that often, never).^d Within the last 2 weeks and on a Likert scale from 1 through 5 (never, not that often, on a regular basis, quite often, always).^e Within the last 2 weeks and on a Likert scale from 1 through 5 (not at all, some, average, mostly, very much).^f One missing reply.

Discussion

The findings from the present pilot study indicate that the patients had experienced the workshop as having influenced their lives in a positive direction, impacted by doing creative writing, sharing and receiving feedback, and the community of the group.

With regards to the impact of writing, most of the patients assessed their writing skills as having improved during the workshop; they had been inspired by the creative writing, had used their senses more, had become more detail oriented, and had felt that the creativity from the workshop could be transferred to everyday life. The female patients tended to use writing as a tool to process feelings about alcohol and other issues – two of them felt that it had had an effect on the reinforcement of positive feelings and alcohol thoughts. Thus, writing functioned for them as a tool to stay strong indicating that the workshop added to their remedies for problem-solving by having a positive impact on executive functioning, in particular attention control and cognitive flexibility, and thereby improved their reasoning functioning. As such, this use of writing as a tool may be the first step on the way to processing hard feelings therapeutically. In a Danish feasibility study, where creative writing was introduced to people with cancer, it seemed as if the patients engaged differently in the exercises depending on where they were in their rehabilitating process after illness (Zwisler, 2017). This may also be seen for AUD patients in relation to where they are in their treatment course. A review of creative writing interventions in treatment for SUD has found that despite limited research in this area, these activities appear to be a viable treatment intervention that can not only lead to decreased drinking intentions, but also to improvements in depression, anxiety, trauma symptoms and physical health in individuals with SUD (Snead et al., 2015).

With regards to the impact of sharing and feedback from fellow patients and the authors, we found that listening with curiosity, acknowledging differences as well as unities, and treating each other with respect had let the patients to become more self-confident and empowered during the workshop. This finding is different from the feasibility study which found that patients were afraid of failing in the exercises or feared to fail in the writing (Hellum et al., 2017). This may be due to the fact that the authors in this present pilot study, from the beginning of the workshop, toned down the importance of grammar and correct spelling. A review of creative writing interventions in treatment for SUD has found that treatment sessions involving creative writing have been linked to improvements in self-confidence/self-esteem, social skills, social/emotional self- expression/self-disclosure, coping, self-awareness and trust in this population. Besides, if clients have not previously had experience with creative writing, leisure skill development may also occur (Snead et al., 2015).

With regards to the impact of the group, some of the patients’ experiences may be ascribed to participating in group activities regardless of those group activities being writing in particular. The patients had, in general, appreciated being together in the group. In particular, they appreciated their differences, embracing opportunities to learn from each other in addition to the coherence in the group grounded in the fact they all shared a story of alcohol dependence. Also, the therapist had experienced that the workshop had facilitated coherence and stigma punctuating. These findings are similar to findings from the feasibility study where the patients felt that being a group created a sense of community and strengthened their sense of unity (Hellum et al., 2017).

Furthermore, our findings indicated that the patients perceived both advantages and disadvantages about discussing alcohol in the workshop. Three patients would have considered a similar workshop in expressive writing on alcohol and dependence a relevant offer. The aims of the two types of writing are, however, different; the purpose of expressive writing is to process one’s life experiences while the purpose of creative writing is to open one’s senses. One other Scandinavian study has found that expressive writing may produce a release of cognitive, emotional, and relational tension in the patients (Gripsrud et al., 2016). Several clinical studies have shown that relative to control group participants, individuals who have written about their own traumatic experiences exhibit statistically significant improvements in various measures of physical health (Stuckey & Nobel, 2010).

Moreover, our findings indicated that the patients experienced an increase in the quality of life measures from the beginning to the end of the workshop, except from one which may be due to one missing reply. Our findings also indicate slight improvements on executive functioning, particularly in relation to reasoning, problem-solving, attention control and cognitive flexibility. But due to the small study group, this is, of course, only small indications and based on the qualitative interviews.

It also seems that the patients experienced attending the workshop positively, that the organization of the workshop worked well, and that, in particular, having professional authors facilitating the workshop was considered inspiring. We found that the patients opted for more time and recommended the workshop being a permanent offer. Both the patients and the therapist considered creative writing to be an addition to treatment with perspectives. This finding is in line with recommendations from a previous feasibility study on a creative writing workshop for a particular group of chronic alcohol patients (Hellum et al., 2017).

During the 2 weeks recruitment period, 10 out of a maximum of 12 patients signed up for the workshop, which indicates a huge initial interest among the patients for a workshop. However, only six patients were continuous which resulted in a 40% attrition rate. The dropout happened primarily after the first session since the workshop was different from the expected. The six remaining patients were satisfied with both the size and composition of the group. Since the study was solely descriptive and qualitative, no essential impact from the dropout will be ascribed to the presented findings. The questionnaire about life quality was based on a small self-report questionnaire. Since the data is based on six patients, the analysis was solely descriptive. The transcripts were not returned to the patients for feedback on the correctness of the transcriptions. Two researchers have coded the data which may enhance the credibility of the analysis (O’Brien, Harris, Beckman, Reed, & Cook, 2014; Thomas, 2006) and increase reliability and internal validity of the findings (Malterud, 2001). Finally, the codes were not stakeholder checked (Lincoln & Guba, 1985) by letting the participants provide feedback on the findings (Tong, Sainsbury, & Craig, 2007). The study design was not randomized. Because of the lack of a control group we cannot attribute the increase of life quality to the writing workshop only. We cannot reject the fact that the patients may have felt better even though they had not participated in the writing workshop.

Conclusion

The present pilot study indicated that there was, indeed, a self-perceived rehabilitating impact of participation in the creative writing and reading exercises. The patients’ overall enthusiasm and gain from the workshop indicated that this kind of creative therapy can add new ways of improving rehabilitation after years of excessive alcohol use: by letting the patients focus on something positive, distracting their minds, making them feel part of a community, and helping them out of isolation and loneliness. Also, the participating therapist had seen potential in the patients she had not noticed before, coherence between people who were very different, and a potential in the workshop as stigma puncturing. As such, this might be a way of opening new doors to the patients’ resources and strengths, thereby improving rehabilitation.

Furthermore, the present pilot study indicated that creative writing may have a positive effect on the patients’ executive functions and quality of life. It seems that the patients increased their quality of life during the workshop, from baseline to follow-up.

The results from the present pilot study, as well as the former feasibility study, indicate that there could be a need for creative writing workshops as add-ons to the ordinary treatment for AUD. In such an offer, creative writing might function as a means to improve patient rehabilitation, quality of life, and executive functions. Hence, future effectiveness studies on creative writing workshops in outpatient treatment for AUD in controlled designs are warranted. In particular, impact on patients’ executive functioning should be investigated in detail with proper measures.

Acknowledgments

The present pilot study is financed by University of Southern Denmark’s strategic research focus area on Welfare Innovation. The authors’ thanks go to patients and staff at the municipal alcohol treatment clinic in Odense. Also, we wish to thank our colleagues at the Unit of Clinical Alcohol Research, Department for the Study of Culture, and Centre for Telepsychiatry. Especially, we would like to thank the authors, Trisse Gejl and Pablo Llambias, who have put huge efforts into this course. During the creative writing workshop sessions, works were used from the following authors: Inger Christensen, Trisse Gejl, Mikael Josephsen, Pablo Llambías, Asta Olivia Nordenhof, and Pentti Saarikoski. Interview templates are available through correspondence with the authors of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.