Gillie Bolton

There's more to writing than getting published. At the most basic level creative writing is a dialogue with the self ? and this is the key to its burgeoning use in modern-day healthcare. Teacher, researcher and practitioner Gillie Bolton puts the case for therapeutic writing and offers some prescriptions for a healthy life.

Apollo is god of both poetry and healing. Writers have probably always known the deeply healing power of writing, certainly since Sappho. But it has been a secret well kept from Western practitioners until recently. Now it is increasingly used in mainstream and complementary healthcare, medicine, and in therapy.

Writing is powerful communication: perhaps even more powerful than speech, as it does not disappear on the breath. Every utterance is a communication between interlocutors. But no one initially listens to a written utterance except the quiet accepting page. The writer is their own first reader, their own primary interlocutor. So writing is, in the first instance, a private communication with the self.

WRITING AS LISTENING

To me, writing is actually a process of deep listening, attending to some of the many voices in the self that are habitually blanketed during our waking lives. Some of those voices we ignore at our peril. This is why people who write for the first time with a trusted facilitator say things like: ?it unlocked something I didn't know was there' (a general practice patient working with a poet-in-residence in a Gloucestershire GP surgery). Someone I worked with said: ?Hell, did I write that? Was that really me? You can't pick something safe with writing, like you can with role-play. I suppose it's because you're not listening to yourself as you write. Writing takes you out of control.'

?You're not listening to yourself as you write.' No, you listen to yourself after you write. And this is the key. The interlocution is delayed until the writer chooses to reread their own writing. while they write, the page offers no judgement at all.

So often we want, but don't really know what. People who over-eat (or drink) know they want, but don't know what, and so they reach for an available comfort ? food or alcohol. It isn't what they really want or need, so they carry on over-eating or drinking, in an effort to stop that terrible crying want.

In a gilt frame above me as I write is a William Blake picture of someone climbing a ladder leant against the moon. The caption reads: ?I want! I want!' We all have an innate right to want ? not quite the moon, but then the person who feels they want the moon has not had their most basic needs satisfied. We are born and we die wanting. That's what we're like, and it's OK. What isn't OK is a constant denial of want, or re-channelling of it into something inappropriate or unsatisfactory.

I suspect my framing of this Blake in gilt is an unconscious irony. There is so much guilt associated with wanting. And it's the cause of a lot of problems. If we can listen to ourselves coherently, lovingly and without guilt then we can begin to understand, begin to communicate with those desperately wanting selves, as well as those loving and wise selves. We can then begin to sort out how to relate to the world in a way which might reasonably bring us a measure of control over our own lives.

Derek Walcott doesn't mention the process of writing when he says, ?You will love again the stranger who was your self'??who knows you by heart' (?Love After Love'), but this is what writing can help you to do. It's a funny thing: we are the greatest authorities on ourselves, yet we are extraordinarily deaf to the ?still small voices' inside, which offer the keys to understanding.

THERAPEUTIC WRITING

How does therapeutic writing differ from creative writing? The former

is intended for a tiny audience ? occasionally none at all, as a writer might choose to therapeutically destroy writing unread. Any audience besides the writer might include family, friends or a healing person.

Almost every creative writer does therapeutic writing; traces of it can be detected clearly in so many novels and poems. But when they come to think of publication, literature writers take their own bleeding heart, anguished mind or tortured body off the page. Because readers are not interested in the writer, they're interested in what the author has to say. Exploring material with therapeutic writers is a deep privilege; but reading this kind of material off a printed page with no relationship to the writer would be boring, and probably seem self-indulgent.

Published authors may well go through the therapeutic initial stages of intuitive writing and sharing material with family, friends or therapist, but they then move on to the rigorous redrafting, crafting and editing stages required for publication.

The redrafting stages can also be deeply therapeutic, as vital images become sharper and more meaningful, as the experience, emotion, or memory is captured as accurately as possible. Writing can be worked on in a way neither speech nor thought can, as it remains unchanged on the page. The etymological roots of the word ?record' are: ?re', meaning again, and ?cord' meaning heart (OED). Redrafting is re-recording, getting closer to what is in the heart each time.

Most therapeutic writers don't bother with these stages ? they don't want to be writers, and the cathartic first stage of writing has brought them a great deal. That's fine, but for those with deep-seated problems these later stages are veritable treasure troves of discovery (though I recommend only trained personnel do writing work with people thought to be psychotic). The distancing involved in redrafting and crafting can also be therapeutic. Anne Sexton's poetry, for example, is deeply crafted; her therapist thought she staved off her eventual suicide by this writing.

Many writers cannot bear the thought of writing being used instrumentally: To them it's an art, not a personal development process. Similarly some therapists and healthworkers feel writers shouldn't work with patients as they have no therapeutic training. But I believe in these boundaries being permeable, and all of us in this uncertain world making as much use of these powers as we can. As Nelson Mandela is supposed to have said, it's not our powerlessness we are afraid of, but our power. Some are afraid of what might be unleashed by the writing hand. I think we need not be afraid to listen, and to extend a helping hand to those who are listening by writing.

Therapeutic writing is increasingly being used within therapy and counselling. It is mushrooming on the internet and email. The Samaritans (www. samaritans.org) runs a very popular email service and Interapy (www.interapy.com) is available on the internet in the Netherlands , and will soon be here. It is offered in general practices, hospices, hospitals, prisons, in substance abuse treatment centres, and so on. We have a vibrant association for writing for personal development in the UK , (Lapidus, www.lapidus.org.uk), and an immensely resourceful National Network for Arts and Health (www.nnah.org.uk). And the medical humanities field ? the use of literature, creative writing, and other arts within medical education ? is opening up dynamically.

HEALTHY MIND, HEALTHY BODY

A surgeon once snapped at me: ?how can writing mend a broken leg?' Well of course it can't, but anyone who knows about the relationship of mind, body and spirit knows that contented people don't get so ill, they experience less severe symptoms when they do, and they recover more quickly. And what makes for happier people? Understanding what they need, not being terrified of what's going on inside them, being able to ask for what they want, and accepting where they are in life.

Dannie Abse, poet, physician, and writing facilitator said in medical journal The Lancet that poems ?profoundly alter the man or woman who wrote them'. There is a thirst for this profound altering, for this deepening of self-understanding and expression. The rash of poems that followed the death of Princess Diana, and 9:11 demonstrate that people have something to express and explore. They need permission to do this with their own grief, anxieties, or memories, not just in regard to an unknown icon such as a princess. We all need this permission, though writing is not the best route for everyone. But it is for many. Get to know the person ?who knows you by heart' better.

WHAT THE DOCTOR ORDERED: WRITING PRESCRIPTIONS

Anxious or ?worried well'

General worry: sufferer may blame someone or something, or may not know what's ?up'

Prescription: interrogating, open explorations

Six minutes Looking at the clock, write for six minutes without stopping, following a train of thought, wherever it takes you. Don't write in sentences or bother with the rules of English. Pick an image, a phrase or even a single word and use it to begin a longer piece of writing.

Dream dialogues Recall your most recent dream and tell its story in the present tense. Ask the main object or character to speak to you and write in this voice. Have a conversation with them, pose questions. Think of the constituents of a dream as parts of yourself: if your brother appears, he may represent your masculine self. But don't worry about ?interpreting'; this process is about listening, tuning in to what's going on internally, and getting beyond the ?topmost' voice that likes to dominate.

Symptomatic depression

Headaches, insomnia, tummy upset, mild obsession. Also past trauma, such as abuse

Prescription: deeper psychological exploration

Metaphor games Explore through animals, seasons, weather, colour. For instance, if your tummy ache was an animal, what animal would it be? If depression is thought to be caused by one's grandmother, ask yourself, what food is she, what colour is she?

Writing as someone or something else Imagine holding an object that's important to you ? how does it feel? Write in the voice of that thing. ?I am the shell my daddy gave me.' Apply this to a person. You may write several versions of one story. For example, one of my patients started to write in the voice of a ward sister from when she was a nurse. The first draft was prosaic, but by the third attempt something more interesting emerged. The voice of the sister was really herself, and it revealed the source of her anxiety. Another application of this is to write in the voice of something observing you ? the chair I sit on, my favourite jersey, my mug; again, it's a safe way of looking into yourself.

Chronic Sick (illness that won't go away)

Longterm illness such as ME, MS or asthma that alters how one thinks about oneself

Prescription: reassessing/reorganising life story to incorporate illness or disability

?My story is broken, I want to mend it' Write a diary, the story of your illness. Focus on feelings (not ?the doctor said this, then this?') by adopting a free-writing style. The story doesn't have to run consecutively, you can dot about; start at whatever point you identify as significant. As you unpack, begin to think about the future, incorporating what has happened into it.

Letters and replies Write to the ill part, for example your gut, or your liver. Say exactly what you feel about it ? anger, hurt, bewilderment, fear. Then, write the reply. It can also be useful to write unsendable letters to someone important, or to a person who troubles you. As before, write the reply. In both cases the ill part or person reflects voices and worries in yourself, and presents a good way of dealing with them.

Survivors: trauma or acute sick (critical illness that will go away)

Anyone who has suffered a trauma ? bereavement, rape, accident or critical illness

Prescription: exorcising the past

Sense stories Pick a memory: the moment you were diagnosed in the hospital, when you felt a lump, arriving home after a mastectomy. Tell what happened, leaving nothing out. What were the colours, the weather, the quality of the consultant's voice? Go into depth. Use ALL FIVE SENSES to describe everything you noticed. By writing about an episode in your illness or trauma you can help yourself to exorcise some of the angst attached to it. Writing is endlessly elastic, it enables you to dot about in time and space. It also allows you to re-tell and re-read. This is about telling as fully as possible: those who have experienced trauma are often compelled to repeat a story that may be hard to tell to other people; writing and re-writing can help get it out of the system.

At the end of life (Terminal illness or old age)

Prescription: reassessing, reorganising, making peace with elements of a life story

Milestones ? (re) writing your life story Think of the most important event in your life, the first thing that comes into your head. Tell the story in depth, writing quickly, dancing over it. Once you begin the process you'll discover other ?milestones' in your life, things you hadn't thought of. As your life unfolds you may well find that an event, or a significant relationship, wasn't quite what you thought it was. Be open to both positive and negative recollections.

Gifts Recall gifts received during your life: who gave them to you? A gift could be the discovery of an eggshell when you were little. Consider things that are less obviously tangible ? what a teacher gave you, for instance. The object of this exercise is to make things concrete; you shouldn't be writing abstractions about your life. Identify what made you joyful. Who made you joyful, or sad?

Substance abuse, anorexia, obsessive-compulsive

Self abuse is a form of obsession. Addiction is a hunger, a need that is being fed artificially.

Prescription: discovering the need that isn't being addressed

Object of desire Write, and answer, and list, one after another, what comes to mind with the following prompts: ?I want?' When that's done, write: ?I wish?' Then, ?If only?' and ?Unless?'. This may involve a long process of unpacking: it often takes a considerable amount of time to get to what it is you really want.

Gillie Bolton (2003) The Best Medicine, Mslexia , OctNovDec 2003 pp23-24