Occupational therapy student Christine Balaba explores writing as tool to be used within occupation therapy, based on her work within acute adult mental health setting. COT Annual Conference 2010 (22-25 June 2010)
I would like to discuss writing as tool to be used within occupation therapy.My presentation is based on the example of a writing group in acute adult mental health which I have been facilitating for the past 5 years.
Co-facilitators: take it in turns to plan to the session Group name: creative writingCosteffectiveness
Clients in competency stage: Lacks awareness of abilities/limitations in unfamiliar activities· Lack of control over occupational outcomes in unfamiliar activities · Expectation of failure in unfamiliar activities· Inability to pursue identified enjoyable activities· Inability to pursue what is most important· Difficulty meeting responsibilities · Difficulty structuring a whole day in meaningful way· Skills not effective in meeting goals · Physical and social environment variable in support
Before I discuss the aims and content of our group I would like to introduce research in relation to therapeutic writing. Group originally developed solely with the main purpose of expressing meaning in writing .Group is still based on these principles (above).
For Pennebaker it is about expressing emotions and its benefits!
Hilse, an OT looked at the use of poetry within OT practice Writing creates and communicates meaning
Members of survivors poetry argue that opportunities to write and share can only be available in a meaningful sense outside of the unequal relationship between health professionals and client. (Sampson & Hart 2005) However recovery starts in hospital, people don’t stop living when they are admitted into psychiatric. For many that’s the time to start planning your life again..., just before you move on...
Not like art therapy or drama therapy, etc. This is were the chance line for OT to develop Writing can stir up a lot of emotion
Writing to bring about change
Goals are in line with the MOHO protocols developed with CNWL Foundation Trust. Group is designed to help patients identify goals, interests, and needs. Clients at this stage may have responsibilities of take a very active role, planning topics for the session, or making suggestions to plan next weeks session. Actively responding to other group members contributions and helping others within the group setting (etc. spelling, encouragement) Making choices is encouraged. Encouraged to set their own goals within group context.
Model of human occupation gives the necessary foundation for the writing, helps us as OT’s to remain occupation focused. The content and topics used within the sessions are planned in line with MOHO. All these areas are considered within planning and carrying out the group
Materials used as inspirations and to give ideas in orderto prepare topics to be explored in the group Stayed away from “poetry workshop”. Some participants find the very mention of poetry off-putting (couldn’t write a poem), but might respond effectively to producing a list, or a letter... So we tried to leave the name as open as possible.
Writing about occupational roles of past, presence and future
Some people may feel silenced, feel unable to speak (cultural or other reasons) ... May still be able to write Sharing the work: Clients are encouraged to share the work Acute admission: experience strong feelings, writing often a way of regulating these feelings (from letters to the Queen to letters to the consultant) Unsent letters are useful for resolving difficult situations (tell what you really think)
Therapist uses the approach required in the situationTherapist would usually participate in the writing process Takes sensitivity from part of the therapist if and what information to share appropriately in the context of the group.
Challenges of writing in mental health and in groupsVolition: Motivation for occupation, poor sense of personal effectiveness (very important how you engage someone for the group, how you label the session) School memory avilitation: writing often can be associated with strong negative emotions (English lessons at school!)Language barrier: we encourage participants to write in any language they would like Stay on acute: varies a lot (months or days) which is a great challenge to continuity. Links with community mental health team in terms of writing in the community would need to be established
MOHOST: completed within two weeks of admission on the ward, performance within the writing group is incorporated
Roles for clients: clients to plan sessionsJournal writing: encourage and facilitate private journal writing Links with the community: writing groups in the community New group on ICU: requires a more structured approach (exploration level)
Woman with an inspiring occupational life history
Writing – A Powerful Tool Enabling Occupational Participation
Writing group<br />Theory behind therapeutic writing <br />Therapeutic writing and OT <br />Model of human occupation (MOHO) as tool for a writing group <br />Challenges <br />Plan <br />
Open group available to clients across two adult acute mental health wards<br />Two co-facilitators (OT and activity co-ordinator) <br />Average: 3-6 participants <br />Weekly: 1 hour <br />Started: May 2005<br />Writing Group <br />
Writing Group<br />Main Inclusion Criteria: <br />Clients at competence stage of the levels of occupational functioning <br />ACHIEVEMENT<br />COMPETENCE<br />EXPLORATION<br />(De Las Heras 2003) <br />
Process of personal, explorative and expressive writing <br />Creative, literary, or autobiographical<br />Client is offered guidance and inspiration and help in choosing a topic for their writing <br />Authority and control of each piece of writing always resides with the writer. <br />Focus is upon the process of writing rather than the product <br />(Bolton and Wright 2004) <br />Therapeutic Writing <br />
Clarify and organise thoughts <br /> (Moskowitz (2005) <br />Allows participants to excel<br />Writing as a means of <br /> personal development <br /> (Hunt and Sampson 2005) <br />Therapeutic Writing <br />
Lack of research apparent (Bolton and Wright 2004) <br />Psychologist Pennebaker(1993, 1997, 1999): <br /> demonstrates the benefits of writing therapy in reducing inhibition and improving both physical and <br /> mental health<br />Therapeutic Writing <br />
Internal connection (with self) and external connection (with others) facilitated through the use of poetry<br /> (Hilse et al 2007) <br />Writing and Mental Health <br />
Communication skills and experiencing writing as a tool for self expression can be utilised outside of a writing group (Williamson 2004) <br />“The very act of writing tends to increase self-confidence, feelings of self worth and motivation for life“ (Bolton 2004)<br />A place for ward-based writing groups within recovery? (Sampson & Hart 2005)<br />Writing and Recovery <br />
There is not one neat theoretical model to guide the use of therapeutic writing <br />(Hunt and Sampson 2005)<br />Words are packets of communications, meanings, ambiguities and implications (Steinberg 2004)<br />Therapeutic Writing <br />
Occupation focused! <br />Writing - opportunity for re-evaluating and planning aspects of life in an occupational dimension (Pollard 2004).<br />Writing and Occupational Therapy <br />
Writing as occupation <br />Writing to reflect <br />Writing as means to plan occupational life <br />Writing to produce a piece of art <br />Writing and Occupational Therapy<br />
Experiences and perceptions of events in order to understand how change in occupational roles takes place (Goldstein et al 2005). <br />Occupation focused narrative, the client’s story should be viewed in terms of what needs to be done next (Hagedorn 2000). <br />Narrator and listener could co-create the narrative and move it forward (Pierce 2003). <br />Writing and Narratives<br />
Competency Phase: <br />Clients will become aware of their abilities and limitations<br />Clients will feel they have control over unfamiliar occupational outcomes <br />Clients will feel positive about succeeding in unfamiliar activities<br /> Clients will be able to meet their role responsibilities<br />Clients will be able to structure their daily routine <br />Clients will have skills to meet their goals<br />Clients will be able to pursue activities within different environments<br />Potential Goals of Clients <br />
Model of Human Occupation <br /> (Kielhofner 2008) <br />
OPHI-II<br />OCAIRS<br />OSA <br />Role checklist <br />WRI <br />Guided fantasy <br />Story starters <br />Topics and tasks suggested by clients <br />Materials <br />
Personal sense of effectiveness <br />Sense of achievement <br />Examples of topics: <br />“Things I am good at?” <br />“Helping others” <br />Personal Causation <br />
What is meaningful to the person <br />Writing as a way of communicating to the therapist and reflecting on their own experience <br />Examples of topics: <br />“A person meaningful in your life” <br />“My perfect day” <br />Values <br />
Person’s interest to write <br />Writing about interests <br />Interest <br />
Example’s of topics: <br />“Roles in my life” <br />“Jobs” <br />“Being a friend” <br />“At the dinner table” <br />Roles <br />
Organise thoughts through writing <br />Planning on paper <br />Example of topics: <br /> “A day in the life of me” <br />Routines <br />
Writing <br />Creativity / Imagination <br />Reflection <br />Processing<br />Examples of topics: <br />“Favourite things”<br />“Cast away on an island” <br />Practicing and Recognising Skills <br />
Communicating to oneself and to others <br />Sharing the work with others <br />Examples of topics: <br />“Unsent letters” <br />“Written dialogues” <br />Communication and Social Interaction Skills <br />
Tolerating <br />Acceptance <br />Writing in a group setting can support the writers in their personal explorations and expressions and it can help to promote trust and a sense of community (Bolton 1999). <br />Social Environment <br />
Collaborating<br />Advocating<br />Empathizing<br />Encouraging<br />Instructing <br />Problem-solving<br />Intentional Relationship Model <br />(Taylor 2007) <br />Role of Therapist<br />
Volition <br />Literacy skills <br />Negative association with writing <br />English language barrier <br />Varied stay on acute ward <br />Strong emotions <br />Challenges <br />
Model of Human Occupation Screening Tool (MOHOST) <br />MOHOST single observation as outcome measure after each session <br />(Parkinson et al 2006) <br />Evaluation <br />
More recent research is needed into the therapeutic effectiveness of writing <br />More research in particular for the use of writing groups and writing in general within occupational therapy <br />Future implications <br />
Clients as facilitators <br />Journal writing <br />Establish more links with the community <br />New group on the female intensive care<br />Plans for the group<br />
“I must write it all out, at any cost. Writing is thinking. It is more than living, for it is being conscious of living.”<br />(Anne Lindbergh, <br />Writer and <br />aviation pioneer,<br />1906-2001). <br />
Bolton, G & Wright, J (2004) Conclusions and looking forward. IN Bolton, G, Howlett, S, Lago, C, Wright, J (ed.) Writing cures. An introductory handbook of writing in counselling and therapy. London/New York: Routledge Taylor & Francis Group, 228-231. <br />Bolton, G (1999) The Therapeutic Potential of Creative Writing. Writing Myself. London & Philadelphia: Jessica Kingsley Publishers.<br />Bolton, G (2004) Introduction: writing cures. IN Bolton, G, Howlett, S, Lago, C, Wright, J (ed.) Writing cures. An introductory handbook of writing in counselling and therapy. London/New York: Routledge Taylor & Francis Group, 1-5. <br />De lasHeras, C, Llerena, V, Kielhofner, G (2003) Remotivation process: Progressive intervention for individuals with severe volitional challenges (Version 1.0). Chicago: MOHO Clearinghouse. <br />References <br />
Goldstein, K. (2004) Occupational narratives and the therapeutic process. Australian Occupational Therapy Journal, 51, 119-124. <br />Hagedorn, R (2000) Tools for practice in occupational therapy. A structured approach to core skills and processes. Edinburgh: Churchill Livingstone. <br />Hilse, C, Griffiths, S, Corr, S (2007) The impact of participating in a poetry workshop. British Journal of Occupational Therapy. 70,10, 431-438. <br />Hunt, C & Sampson, F (2005) Introduction. IN Hunt, C & Sampson, F (ed.) The self on the page. Theory and practice of creative writing in personal development. London: Jessica Kingsley Publishers, 9-18. <br />Kielhofner, G (2008) Model of Human Occupation. Theory and Application. Baltimore: Lippincott Williams & Wilkins. <br />References <br />
Lindbergh, A (1974) Locked Rooms and Open Doors. Diaries and Letters of Anne Morrow Lindbergh, 1933-1935. Washington: Harvest Books. <br />Parkinson, S, Forsyth, K, Kielhofner, G (2006) A User’s Manual for the Model of Human Occupation Screening Tool (MOHOST). London: UK Centre for outcomes, research and education.<br />Pennebaker, J & Seagal, J (1999) Forming a story: the health benefits of narrative. Journal of Clinical Psychology, 55,10, 239-245. <br />Pennebaker, J (1993) Putting stress into words: health, linguistic, and therapeutic implications. Behavioral Research Therapy, 31, 539-548. <br />Pennebaker, J (1997) Writing about emotional experiences as a therapeutic process, Psychological Science, 8,3, 162-166. <br />Pierce, D (2003) Occupation by design. Building therapeutic power. Philadelphia: F.A. Davis Company. <br />Pollard, N (2004) Notes Towards a Therapeutic Use for Creative Writing in Occupational Therapy. Chapter 10. In Sampson, F (ed.) Creative Writing in Health and Social Care. London & New York: Jessica Kingsley Publishers, 189-206. <br />References <br />
Tailor, R (2007) The intentional relationship model: occupational therapy and the therapeutic use of self. Chicago: F.A. Davies. <br />Steinberg, D (2004) From archetype to impressions; the magic of words. IN Bolton, G, Howlett, S, Lago, C, Wright, J (ed.) Writing cures. An introductory handbook of writing in counselling and therapy. London/New York: Routledge Taylor & Francis Group, 44-55. <br />Williamson, C (2004) On the road to recovery: writing as a therapy for people in recovery from addiction. IN Bolton, G, Howlett, S, Lago, C, Wright, J (ed.) Writing cures. An introductory handbook of writing in counselling and therapy. London/New York: Routledge Taylor & Francis Group, 123-129. <br />Wright, J (2004) The passion of science, the precision of poetry: therapeutic writing – a review of the literature. IN Bolton, G, Howlett, S, Lago, C, Wright, J (ed.) Writing cures. An introductory handbook of writing in counselling and therapy. London/New York: Routledge Taylor & Francis Group, 7-17. <br />References <br />