“Living poets society” – a qualitative study of how Swedish psychologists incorporate reading and writing in clinical work

ABSTRACT

Different forms of reading and writing can have therapeutic effects and therefore beneficially are incorporated into mental health care. In Swedish mental health care such incorporation is not established but the field is gaining increased interest. In this study, five psychologists in Swedish mental health care who incorporate reading and writing in their clinical work were interviewed about how they incorporate such activities and how they perceive reading and writing in terms of patient recovery. An Interpretative Phenomenological analysis resulted in the following themes: New perspectives, The psychologists’ perceptions, Shared symbols, Freedom to express oneself, and Safety through structure. The results show a need for flexibility in clinical work; since unique individuals express themselves in different ways, practitioners should be encouraged to offer patients opportunities for creative expression. It is suggested that reading and writing need to be established as valid and easily identifiable interventions in Swedish mental health care.

KEYWORDS:

• Bibliotherapy
• creative writing
• mental health care
• person-centered care
• poetry

This study concerns how clinical psychologists incorporate reading and writing in Swedish mental health care. Until now, such interventions have been relatively unknown and unestablished in Swedish mental health care, but research and clinical practice centered on reading and writing seem to be on the rise. Pohl et al. (2018) for example wrote about integration of poetry and psychotherapy and argued that poetry therapy should be offered to clients who might benefit from, or appreciate it. Pettersson (2018) has studied how bibliotherapy contributes to recovery among individuals who attend an activity center for people with mental health difficulties. She found that reading contributes to self-confidence, social interaction, and wellbeing.

This resonates with international studies that show long-term effects of bibliotherapy in treatments aimed at depression and anxiety (Gualano et al., 2017; Popa & Porumbu, 2017). Moreover, Adler et al. (2013) analyzed patients’ narratives about the therapeutic process and their sense of self, in terms of two components: the meaning-making process and meanings made. They found that processing difficult experiences and creating one’s own narrative was associated with sudden gains in treatment, indicating that meaning making is essential for recovery. Pennebaker (1993, 1997) has studied the effects of expressive writing on psychological and physical wellbeing. He argued that writing could be incorporated in mental health care (Pennebaker, 1993) since it supports insight, a cohesive narrative, and emotional expression. Also, psychotherapy researchers Summers and Barber (2012) described that autobiographies, poetry, and artwork might support self-expression and self-understanding and therefore they recommend integration of reading and writing in psychotherapy. Moreover, Macnaughton et al. (2015) invited patients with psychotic experiences to write about their path into mental health care. According to the participants, writing supported understanding and acceptance of one’s life-story. Moreover, studies have shown that reading and writing might support recovery among patients with for example depression and anxiety (Brewster, 2011) and traumatic experiences (Schwietert, 2004).

Mazza and Hayton (2013) have presented an open and flexible poetry therapy model, which is divided into three components. The first one is called receptive/prescribed which means that poetry, or other forms of literature, is presented to the patient. The purpose is to validate the patient’s feelings, encourage sharing of experiences and, when done in group therapy, participate in discussions. The second component is called expressive/creative. The patients are encouraged to express themselves through different forms of writing, for example poetry, letters, diaries, or stories which allow them to approach and express their emotions. The last component is called symbolic/ceremonial. Here, metaphors, rituals, symbols and storytelling become a way to cope with challenging or traumatic life events (Mazza & Hayton, 2013).

Also, Richards (2007) has presented an open approach to creative activities and their impact on wellbeing and recovery. She focuses on everyday creativity, defined as the ability to create something that is characterized by meaningfulness. Everyday creativity might concern artistic activities but may take other forms such as mechanics developing their own tools, or engagement in gardening or cooking. Everyday creativity opens up for alternative ways to feel, for truth and beauty as well as for managing life situations both on an individual and on a societal level (Richards, 2007). Everyday creativity is an essential but under-valued part of life that is necessary for presence and ability to experience life, and accordingly for health and wellbeing.

In order to understand how patients in mental health care perceive reading and writing, personal experiences need to be acknowledged. O’Donovan (2011) described how creative writing helped him towards a more meaningful life after being diagnosed with episodic bipolar disorder. Writing also increased his awareness of feelings and thoughts and how they change over time, which contributed to insight (O’Donovan, 2011). Another perspective was offered by Cooper (2014) who wrote about Linda, a patient diagnosed with schizophrenia and depression. Her treatment incorporated writing. Six weeks post-treatment, Linda was asked to comment on her experiences of writing. She described that she re-read her writings and thus was able to see herself and improve her self-perception (Cooper, 2014).

Poetry therapy is an internationally expanding field. Interest is increasing in the Nordic countries, as indicated by newly established journal Nordic Journal of arts, culture and health (2019). Even though poetry therapy is not yet established in Swedish mental health care, or in research institutions aimed at mental health care (Pettersson, 2014), there are Swedish psychologists who incorporate reading and writing in their clinical work (Punzi & Hagen, 2017). Knowledge concerning how this integration takes place is however limited. This study focuses on how psychologists who work in Swedish mental health care incorporate reading and writing in treatment. The aim of the study is twofold. The first is to gain knowledge about how clinical psychologists incorporate reading and writing, or other creative activities, in their clinical work. The second is to understand how they value reading and writing in terms of patient recovery. Interviews with licensed psychologists who incorporate reading and writing in their clinical work were performed.

Materials and methods

Participants

The participants were recruited through a network of psychologists, literary scholars, and librarians (and students within these disciplines) interested in integrating reading and writing and mental health care. Six psychologists were contacted through e-mail. They were given information about the aim of the study and were invited to participate. One of the approached psychologists did not respond. The others agreed to participate. Accordingly, five psychologists participated, two men and three women. Before the interviews started, the psychologists had the opportunity to ask questions, and they were informed that participation was anonymous and that they could discontinue their participation at any time. Thereby they could make an informed decision about participation.

All five participants have more than ten years of clinical experience and describe themselves as eclectic. They all work in adult mental health care. In order to maintain anonymity, the participants have been given assumed names. As the gender of each participant is not considered relevant to this study, and to further ensure anonymity, their gender is not presented and they were given non-gendered names. Throughout the paper, the pronoun she is used.

Alex works at a treatment unit aimed at clients who suffer from mild to moderate anxiety and depression. Alex does not use a particular reading or writing method.

Robin works both at a psychiatric outpatient clinic and an activity center aimed at individuals who have been or are in contact with psychiatry. There she works with groups in which texts are read and discussed.

Chris works at a psychiatric outpatient clinic and often treats patients with traumatic experiences. Chris uses a method of creating a life narrative through writing.

Mika works at an addiction treatment unit. She incorporates writing flexibly in individual therapy, and more systematically in writing groups.

Kim works at a psychiatric outpatient clinic. She does not use a particular reading or writing method.

Interview

The interviews were performed in a place and at a time chosen by each participant. Four interviews were performed at the participants’ work place, one at the Gothenburg university.

The semi-structured interviews were performed by the first author. In order to capture the participants varied experiences, it was deemed important to pose open questions. An interview guide with areas of interest, rather than specific interview questions, was therefore created. This is in line with recommendations for data collection for an Interpretative Phenomenological Analysis (IPA). Ogden and Cornwell (2010) also stated that open questions contribute to richer and more detailed data. The five areas were: (1) The psychologists’ own experiences of reading and writing, (2) Whether they think specific groups of patients benefit from reading and writing, (3) Decisions and timing concerning whether and when reading or writing should be introduced, (4) How reading and writing activities are incorporated and carried out, and (5) How genres and texts are selected and used. Within each area, the interviewer asked for specific examples. Follow-up questions were asked in order to clarify the participants’ experiences.

Each interview lasted about an hour and was recorded using the Voice Recorder (Windows) directly on the laptop. Thereafter they were transcribed verbatim.

Analysis

Each transcript was imported into NVivo 12, coded and sorted into sub-themes and themes. The transcripts were analyzed according to IPA. The aim of IPA is to understand how the participants make sense of the studied phenomenon and the method is recommended for studies concerning individual experiences and perceptions (Larkin et al., 2006; Smith, 2011). In line with Willig’s (2008) recommendations, the first step of the analysis was to carefully read and re-read each transcript to achieve a sense of how the participants express themselves as well as an understanding of the content of each interview. In the second step, statements judged as relevant for the study were given descriptive codes. The third step was to group codes with similar content into provisional sub-themes, relevant for each participant. These sub-themes were compared to the transcripts, in order to ensure that each sub-theme captured what the participant had related in the interview. In the fourth step, sub-themes with similar content were sorted into five themes which captured the content of all five interviews. At this stage the naming of the sub-themes and themes were evaluated and refined to capture the participants understandings of the studied phenomenon. Lastly, these five themes were compared in order to identify similarities and differences between the participants. The number of participants who spoke about each theme is presented in Table 1. Thereafter the five themes are presented and illustrated with quotations.

Table 1. Themes and participants who discussed each theme.

Theme	Participants who discussed the theme
New perspectives	Kim, Mika, Chris
The psychologists’ perceptions	Kim, Mika, Robin
Shared symbols	Kim, Alex
Freedom to express oneself	Mika, Chris, Alex
Safety through structure	Mika, Chris, Robin

Results

New perspectives

The participants sensed that reading and writing, as well as other creative expressions and popular culture, could support the patients to see a situation, or themselves, in a new way. The patients gain perspective as to what has happened, what they do or did, or who they are. According to the participants, this new perspective can help the patients see themselves and their behaviors in a way they have not been able to do before. Kim gave an example of how this can happen through a dialogue about a movie.

One makes excuses … I buy sex and there’s nothing strange with that, it’s like any merchandise. She’s allowing it … Then you watch, like Lilja Forever¹ perhaps - So what do you think when you’ve seen that movie? How willing is she? What is she willing to? Do you want to accept a shiny picture of what you do? And this can be a way to approach reality.

New perspectives can also arise when a book or a movie reminds the patients of something they have experienced, and they recognize themselves or their reactions in a character. The participants understood this as an outside perspective; through literature or a movie, the patients approach their experiences from the outside which is less threatening and allows them to reflect on the situation and themselves. Such recognition can lead to the patient feeling less alone or deviant. There is a sense of normality and insight into the fact that people sometimes behave senseless. This can support the patients to see themselves in less judgmental ways. Fictional characters also have the capacity to show someone else’s perspective. Thereby situations might be perceived from different viewpoints. The participants described how patients in this way sometimes can find the courage to see how their own actions have had negative consequences, for themselves as well as for others.

Moreover, the participants sensed that curiosity and a sense of humor may foster new perspectives. This might be achieved through a playful approach, of course when appropriate, and some easy-going or humoristic moments in an otherwise often difficult therapeutic process. Humor was understood as the opposite of rigidity and therefore as a potential entrance point to a more flexible approach to oneself and one’s difficulties. The importance of a sense of humor in gaining new and different perspectives was expressed by Kim in the following quote;

… humor is some kind of opposite to rigidity, there is some kind of flexibility in humor. The whole point of humor is, or a large part of humor, is to be able to laugh at what’s crazy, wrong or ugly and a little forbidden, and in laughter maybe we can find courage to approach something in a different way.

The psychologists’ perceptions

This theme represents the participants perceptions of reading and writing and why they came to incorporate reading and writing into their clinical work. Several participants perceived that reading gives them a deeper understanding of the world, themselves, and other people, and connected this understanding to their clinical work. They sensed that since psychologists basically use themselves as tools when they encounter their patients, their personal interest in reading and writing has become a natural part of their work. Alex explained it with the following words;

Well, I’ve always had that in me I think … That one can … you can do that. A pretty natural thing, but maybe that’s because it’s natural to me. I have written a lot myself, when I’ve been thinking and mulling over things.

Mika described how her personal experiences of writing gives her an understanding of what the writing process can do. Therefore, it has become a natural part of a therapeutic process;

… I write myself and that means that …  somehow I know what it means to put words to something. Not just write the letters or hit the keys but what it does to me emotionally and to my soul, and to me as a person and what I am actually doing. Because I’m really very interested in this. What happens between what’s in my mind, my thoughts and my emotions. I transfer it, through language, into the world.

Several participants perceived that one need some courage to suggest reading and writing to a patient, without knowing how the suggestion will be received. The participants sensed that negative school experiences can cause some patients to hesitate, or even refuse, interventions centered on reading and writing. They did not identify any risk of harming the patient by suggesting reading or writing but sensed that a strain in the alliance between the psychologist and the patient could be invoked if the suggestion was met with resistance or refusal. Such as strain could however be reflected on an overcome and therefore was understood as a risk worth taking. The participants also sensed that in a treatment climate that is increasingly centered on structured interventions, they needed courage to introduce and argue for non-structured creative interventions in relation to colleagues who are more interested in structured methods.

Shared symbols

According to the participants, literature, lyrics, movies, or TV-series are shared cultural symbols that might be a starting point for talking about experiences, emotions, or how a situation could be understood. Sometimes, the participants are reminded of a book, a movie, or a character when they are listening to their patients and might ask the patients if they recognize anything in the character or the situation. Some participants express that they need to dare to introduce a symbol or metaphor, for example from a movie or a television series, in order to confirm a shared understanding. In other cases, the patients spontaneously say that they feel like the character in a movie or a book. The character becomes a shared symbol for the psychologist and the patient and reflections on the character facilitates reflection on experiences and emotions. For these metaphors and symbols to be meaningful, both the psychologist and the patient must be familiar with the piece of fiction referred to, as explained by Alex.

Then I think, associating to movies, literary fiction and all kinds of things like that … music and so on. I think that it is very important and useful in therapy and …  in the conversations. Well it was just like that, did you read that book? It was just like that … like it’s there … I think it is really important.

Freedom to express oneself

The participants also sensed that the freedom to express oneself in whichever way one feels comfortable with, supports recovery. Such openness gives the patient control over what is being communicated, and how it is communicated. In treatment, the focus is often on problems or behaviors and duties the patient is unable to accomplish. The freedom to express oneself in a way one feels comfortable with offers an opportunity to also focus on the patients’ abilities and on activities that are considered meaningful. According to the participants, it is important to identify the patients’ abilities and interests since experiences of being a capable person strengthen one’s sense of self.

The freedom to express oneself is also about permitting the patient to decide how to express themselves, which is specifically important when it comes to difficult experiences. Individuals use different forms of expression with varying ease and psychological treatment often takes the form of conversations. Experiences that are too difficult to talk about might instead be approached through writing. Moreover, the freedom to express oneself through a poem can foster new experiences, since a creative space opens up. In the following quote, Mika describes how a patient could move forward in life after having expressed herself in ways that were personally meaningful and available to her.

A lot of things happened with this individual because she … was given permission, and was encouraged to use language. There was great development in that person’s life after that.

Adjacent to this, the participants reflected on the current emphasis on structured treatments aimed at symptom reduction and described that it could be difficult to include open interventions in which patients could express themselves freely. They sensed that their work with reading and writing could be perceived as controversial and not in line with so-called evidence-based treatments. Non-structured and non-directive parts of treatment was understood as important for creating an atmosphere in which people could express themselves freely. As Mika explains;

We also have coffee (laughter) … a nice cup of coffee …  and make ourselves comfortable. We are …  a small “writing society”, not dead ones but Living poets society.

Safety through structure

The participants simultaneously discussed the need to create structure that ensures safety for their patients; freedom and structure exist alongside each other. Structure may concern a concrete structure, such as seeing each other the same time and place each week. Structure also concerns expectations about how to express opinions and reactions. Clear boundaries were understood to create the safety needed for patients to express themselves freely. The following quote is from Mika, who works with groups;

… if you don’t want to read you don’t have to and if you choose to read the others are expected to be respectful towards what is read. And to look for something inside oneself, what resonates within you and that is what is being communicated. Politely and ideally with warmth (laughter) … not rose-colored but something that is true to oneself. That’s what we’ve said.

Language was also understood as creating a structure, since language supports the organization of emotions and experiences. Thereby, the development of an own narrative is fostered and in this process experiences that are perceived as chaotic or overwhelming might be approached. Chris explains it with the following words;

It’s the same principle really, that there’s an order, a structure in language. If you think more generally about writing and reading. Reading, that’s different. But to write, it is …  to write your story or tell your story …  it creates order since order is created through the language. It’s a characteristic of language, as I see it. That it is ordered, structured.

Writing could be specifically important for patients who sense that their memories, emotions and experiences were fragmented, for example following trauma, since writing brings a structure to the narrative. The participants sensed that for some patients, it was easier to articulate their memories, experiences, thoughts and emotions through writing. Accordingly, writing could be important for recovery.

Discussion

The participants in this study incorporate reading and writing in their clinical work in varying ways. One participant uses writing as a specific method in treatment of trauma, others declare that their work is not grounded in any specific method. Interventions include shared reading, creative writing, writing timelines, diaries, and conversations about various forms of creative expressions and popular culture. The participants do not perceive reading or writing as specifically suitable for certain groups of patients in terms of age, gender, background or diagnosis. To them, it is more about whether the patient perceives reading or writing as something that is, or could be, meaningful and appreciated. This is in line with Mazza’s (1993) conclusion that people who enjoy reading are more open to bibliotherapy while people who enjoy writing are more positive toward interventions centered on writing. Some participants mentioned that patients with negative school experiences might hesitate or refuse to read or write. It should be noted that the patient’s willingness to engage in reading or writing might depend on how the activities are presented to them. Invitations to write stories might for example be perceived as more demanding that writing for example diaries or poems. It is also possible that our participants have a frame of reference that differs from their patients’ and therefore they may overlook everyday creative activities (Richards, 2007) that are meaningful to some of their patients. The participants are aware that popular culture such as movies, might be meaningful for their patients which is in line with the openness of poetry therapy as described by Mazza’s (2017). The participants also perceived metaphors and symbols as important, which is similar to the symbolic component in Mazza and Hayton’s (2013) model. They also sense that they and their patients need to have a shared frame of reference and be familiar with the metaphor or symbol. Popular culture might offer such a shared frame of reference. It is more likely that patients have seen a popular movie that read a less accessible piece of literary fiction. It doesn’t matter what qualities the literary piece has; the movie is still a better metaphor.

Several participants understand reading and writing as activities that support the ability to take different perspectives. This is in line with Djikic and Oatley’s (2014) findings that fiction can start a process of change, involving improved empathy, since literature offers a simulation of oneself in the social world which is a precursor to change. Similarly, Mar and Oatley (2008) found that literary narratives simulate the social world and offer the reader an experience of social interactions. They suggest that such a simulation supports understanding of social interaction through indirect experiential learning. Similarly, our participants had experienced that fictive characters could be important for their patients’ ability to see themselves and their situations from new perspectives. According to our participants, the ability to see different perspectives is crucial for patients who experience alienation. These patients may recognize themselves in fictional characters and understand that others have similar experiences which may contribute to a sense of worth and to decreased sense of being deviant. Our participants also emphasize the patients’ need to feel safe in order to express themselves freely, a perspective that is shared by psychotherapy researchers Summers and Barber (2012). There were different ways to achieve a sense of structure and safety, for example through clear expectations about communication. This has also been reported by Baker and Mazza (2004), who describe the importance of patients knowing that others will take their writing seriously and respect their integrity.

According to Pennebaker (1993), writing permits emotional expression, increased understanding, and the development of a narrative, and therefore is helpful. Macnaughton et al. (2015) found that patients with psychotic experiences, who wrote about their pathway into care, increased their understanding and acceptance of their life and their difficulties. Adler et al. (2013) also found that creating a meaningful narrative was associated with therapeutic progress. The participants in our study indeed emphasize expression, understanding, and the personal narrative. The participants thus seem to have an intuitive sense of how to incorporate reading and writing in their clinical work, that is line with results from research studies as well as poetry therapy methods. Nevertheless, the participants mentioned that they lack scientific support and contrasted reading and writing interventions to structured or manual-based treatments. They invite patients they think might benefit from reading or writing and allow their patients to decide if this is possible and meaningful to them. The participants spoke about courage and the need “to dare”. This gives the impression that the participants, even though they are all well-educated and experienced, sense uncertainty connected to a perceived lack of research support. This is interesting as for example bibliotherapy has research support (Brewster, 2011; Gualano et al., 2017; Pettersson, 2018), a fact the participants may be unaware of. The participants are however aware that their patients might benefit from reading and writing, even though there are no guidelines for incorporating such activities in Swedish mental health care. Their awareness might be seen as a resource. We therefore suggest that practitioners should be empowered to invite patients to engage in reading and writing, and other creative activities the patients find meaningful. To do this, decision makers and superiors need to appreciate that the difficulties that made the patients seek out mental health care cannot be treated isolated from the life circumstances of the individual, hers/his interests and capabilities, or what s/he finds meaningful (Elkins, 2004). Practitioners and patients should be permitted to make mutual decisions regarding individual treatment.

Such mutual decision making might however be complicated, since Managed care and New Public Management have become common management systems within Swedish health care (Andersson Bäck & Lane, 2016). The purpose is to achieve cost-effective goal-oriented care, but the consequences are expectations to measure everything, uniformity of treatment interventions that cannot capture complex human suffering, and underestimation of social conditions (Hammarström, 2016). Open and flexible treatments do not fit into this model and are becoming increasingly rare in Swedish health care. Nevertheless, our participants emphasized the importance of openness and flexibility. This is in line with suggestions from researchers Punzi and Hagen (2017) who propose that different forms of creative expression should be seen as natural resources and their incorporation into psychological treatment should be encouraged. Moreover, Topor et al. (2018) studied the importance of micro-affirmations for recovery among patients in mental health care. Micro-affirmations refer to supportive everyday interactions that occur in unexpected situations. A practitioner might say or do something that does not have a direct therapeutic meaning, but paradoxically become therapeutic. Topor et al. (2018) suggest that during such moments, patients may sense that the difference in power between practitioner and patient is momentarily erased, an experience that might support sense of self-worth as well as agency. The participants in our study discuss reading, writing, and movies with their patients and these dialogues could be seen examples of micro-affirmations that enhance recovery. Such dialogues were however perceived as being on the border of a psychologist’s professional role which likely contributed to our participants’ sense that they need to be courageous.

Even though so-called managed care has become mainstream, the Swedish National Board of Health and Welfare (Socialstyrelsen, 2016) recommends person-centered care. Accordingly, we submit that mental health practitioners should be supported to offer reading and writing interventions when it is considered relevant. This study focused on psychologists who already incorporate reading and writing in their clinical work. It is likely that practitioners from other disciplines such as social work and occupational therapy also incorporate reading and writing. Since such incorporation mostly seems guided by the personal interest of the practitioner, it is deemed difficult for patients to actively seek out such treatment. Patient-centered care would be improved if patients could identify practitioners and treatment units who acknowledge reading, writing and other creative expressions as adequate interventions. We therefore suggest that practitioners and treatment units who integrate such interventions announce this when they present themselves to patients and other caregivers. This would also be a resource for practitioners looking for colleagues they could share experiences and ideas with. Thereby, practitioners could also learn from each other and steps could be taken towards formalizing and establishing reading and writing as valid treatment interventions within Swedish mental health care, not least poetry therapy with its openness and flexibility. A final reflection concerns the need to consider the consequences of a strong emphasis on structured treatments. Even though this study concerns Swedish mental health care, the tendency to overlook everyday creativity and meaning making is not limited to the Swedish context. Treatment that is focused on meaning making and everyday creativity demands patient-specific considerations. Such considerations cannot be captured by research and clinical practice that holds uniform treatment interventions and randomized controlled trials as a golden standard (Goldfried, 2016). Practitioners need to acknowledge structured treatments that are supported by research, but they also need the flexibility to integrate different methods (Summers & Barber, 2012). This means that not only patients, but also practitioners need to develop their capacity to take different, and new, perspectives.

Limitations and future research

This study has its’ shortcomings. It is based on the experiences and perspectives of a limited number of psychologists who work in the same part of Sweden. The participants were approached because they are interested in the field and accordingly, they might exaggerate the importance of reading and writing. Moreover, the openness of the study makes it somewhat unfocused. The openness simultaneously permits varying ways of incorporating reading and writing to be revealed. It also turned out that the interventions are not limited to reading and writing but might concern other creative activities and popular culture. Future studies should focus on specific aspect of reding and writing, for example the differences between creative activities in group settings compared to individual therapy. Future studies should also focus on how practitioners other than psychologists incorporate reading and writing in their clinical work. Of course, future studies also need to emphasize the perspectives of patients, and investigate their perceptions of how, when, and why reading and writing as well as other creative activities should be incorporated in treatment.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 Lilja forever is a well-known Swedish movie about Lilja, a young woman who is a victim of trafficking.