Is poetry therapy an appropriate intervention for clients recovering from anorexia? A critical review of the literature and client report

ABSTRACT Poetry therapy is an arts-based psychotherapeutic intervention, often delivered in groups. This paper argues that the process and benefits of poetry therapy may be particularly suited to clients recovering from anorexia, as an adjunct to other treatments. Poetry therapy and its history are described briefly, and the relevance of poetry therapy for clients recovering from anorexia is outlined. After one client contributes her experience of this treatment for illustration, the paper offers a review of the evidence base for poetry therapy for eating disorders, and argues that, while research is limited, further research is warranted. Finally, a description of one form of clinical application is offered, to enable replication.

. Developing an understanding of oneself and others through poetry and other forms of literature . Promoting creativity, self-expression, and greater self-esteem . Strengthening interpersonal and communication skills . Expressing overwhelming emotions and releasing tension . Promoting change and increasing coping skills and adaptive functions (Gorelick, 2005, p. 119)

Process, characteristics and benefits
Like other expressive or arts-based therapies, poetry therapy is characterised by the use of the imagination, imagery and metaphor (Hedges, 2005;Malchiodi, 2005). By enhancing self-expression, poetry therapy can also enable independence from therapy (Alschuler, 2006), which is an important aim in more chronic presentations. Importantly, poetry therapy is presented 'as a tool, not a school' (Gorelick, 2005, p. 124), in that it can be practiced by a range of professionals across a spectrum of psychotherapeutic models. For example, poetry therapy in psychodynamic practice may focus on catharsis and unconscious processes (Perlin, 2009) or the written word as a transitional object (Steinberg, 2004), whereas poetry therapy in existential practice may focus on giving voice to unfolding experience, clarifying and magnifying being (Furman, 2003), or maintaining vitality in the face of the givens of existence (Gorelick, 2005). It can also be a culturally-sensitive practice, particularly where poetry, lyrics and language form a strong part of a client's cultural heritage (Mohammadian et al., 2011;Reynaga-Abiko, 2008). It can be a developmentally-sensitive practice as well, as adolescents may already be using poetry and lyrics to identify, articulate and communicate their feelings (Reynaga-Abiko, 2008).
There is a rich literature documenting how different clinicians have incorporated poetry into their therapeutic work (Nylund, 2002;Speedy, 2004). Alschuler (2006) stated that poetry therapy is usually offered as a group-based intervention, and many other practitioners attest to the therapeutic power of poetry in group work (Bolton, 1999). McLoughlin (2000) presented an excellent case study describing a poetry therapy group offered from a psychodynamic perspective in a hospice. He has described how the group functioned as a transitional space, after Winnicott (1971), while offering consolation and a space for growth and development during a time of change. In this sense, poetry therapy can be particularly suited to ward-based work, with some authors describing how poetry therapy can enhance bonds between patients (Golden, 1995;Leedy, 2006). However, this intervention can be difficult to access for clients with learning disabilities such as dyslexia or clients who have had difficult experiences of schooling. Treatment targets the ability to symbolise, by supporting clients to access metaphor and imagery (Bolton & Latham, 2004). So, while clients who lack imaginal capacity can be difficult to engage, the intervention targets this deficit in its attempts to repair the bridge between the body and experience.
Many writers agree that poetry therapy is most effective as an adjunct to therapy (Heimes, 2011;Mazza, 2003;McCulliss, 2012;Perlin, 2009), in part to support clients with the painful process of accessing difficult emotions and experiences (Esterling, L'Abate, Murray, & Pennebaker, 1999). This strengthens the case for this intervention to be offered as part of a package of care, such as in psychiatric hospitals, where poetry therapy can encourage expression, peer interaction and engagement in groups through the use of an expressive, 'strength-based technique' (Kerner & Fitzpatrick, 2007, p. 333) that can potentially be less confrontational or threatening than other groups (Alschuler, 2006).

Anorexia nervosathe need for innovative treatments
Anorexia is often a complex presentation, where new, accessible and cost-effective (i.e. group-based) treatments are needed (NICE, 2004;Reynaga-Abiko, 2008). As East, Startup, Roberts, and Schmidt (2010) have pointed out, anorexia nervosa lags behind other psychiatric disorders in terms of evidence and treatment. Writing is already used in many treatment programmes for anorexia, by perhaps writing letters to anorexia my enemy and anorexia my friend as a motivational intervention, or encouraging clients to externalise anorexia as a bully through their writing from a narrative perspective (Schmidt, Bone, Hems, Lessem, & Treasure, 2002;Treasure & Alexander, 2013). Clients recovering from anorexia often voice their dissatisfaction with traditional treatments, which can be experienced as reductionist, with staff appearing to focus primarily on weight gain (Robbins & Pehrsson, 2009). There is a need to create space for clients' ambivalence around recovery, which is why poetry therapy is being explored as a particularly appropriate and creative intervention for anorexia (Kaplan, 2002;Robbins & Pehrsson, 2009). Developing new treatments for anorexia can be difficult, however, due to the high levels of avoidance that are a part of the presentation (Schmidt et al., 2002). There is a need therefore for new and effective treatments which specifically target avoidance (Frayne & Wade, 2006).

Poetry therapy and anorexia
Is there a case for considering arts-based psychotherapeutic interventions using creative writing, literature and poetry as particularly suitable for clients recovering from anorexia? East et al. (2010) have argued that writing-based treatments can target experiential avoidance through exposure to feelings and thoughts, thus improving psychological flexibility. They cite Pennebaker's (1997) work as they contend that these interventions also target the difficulties expressing emotions commonly seen in anorexia, through a 'disinhibitory' effect (East et al., 2010, p. 181). They also suggest that engagement with emotional experience is key to recovery from anorexia, which is why treatments which focus more on cognitive control over their environment (i.e. CBT) are less effective with this presentation. Hornyak and Baker (1989) also observed that clients recovering from eating disorders can present as very cut off from themselves, emotionally and cognitively, and that experiential and arts-based therapies can help to re-build that bridge. Schmidt et al. (2002), Howlett (2004) and Treasure and Whitney (2010) have all described writing-based treatments that can be used as 'a way in' to facilitate emotional expression and processing in order to address or challenge misattributionswhich can then increase support and understanding between families and clients, reducing isolation and stigmatisation (Schmidt et al., 2002). Importantly, Alschuler (2006) and Boone and Castillo (2008) also have written that poetry therapy may be particularly useful with 'resistant' or highly defended clients, as the intervention is explorative and works indirectly, enabling reflection and revelation. Writing poetry is cathartic, and so can help to express feelings, increase confidence through risktaking, enhance insight, and reduce anxiety (Alschuler, 2006). Alexithymia is commonly experienced by clients affected by anorexia and many other mental health presentations, and has been shown to have debilitating effects, even after controlling for other factors (Stockdale, 2011). Treatment, as in therapeutic creative writing, becomes about expression (Howlett, 2004;L'Abate & Sweeney, 2011). Poetry therapy may be able to assist alexithymic clients to identify and experience emotions as opposed to somatising them or acting them out (Alschuler, 2006;Stockdale, 2011). Research into the use of expressive writing in particular indicates the benefits of integrating and organising experience by translating it into a narrative, which creates distance from the events, improves perspective and increases a sense of control (Treasure & Whitney, 2010). Further, East et al. (2010) have reasoned that perspective-taking could be among the mechanisms by which writing can target the theory of mind deficits which are often observed in clients recovering from anorexia.
Where anorexia cannot be managed in the community, there is a need for psychiatric group interventions for day patients or inpatients which can encourage engagement in group therapy. Alschuler (2006) has made the case that poetry therapy, like other art therapies, is particularly suitable here, as it can encourage expression and peer interaction in a less confrontational or threatening way than a more intense group psychotherapy. Poetry therapy also has the potential to be an empowering intervention for clients recovering from anorexia. As it is focused on meaning and expression, and not solely on weight gain, it can give voice to clients' experiences, and help to shift any sense of blame from the self to the disorder (Robbins & Pehrsson, 2009), using narrative and other approaches to encourage the externalisation of the anorexic 'bully' (Treasure & Alexander, 2013). Woodall and Andersen (1989) provided an excellent psychodynamic conceptualisation of the experience of anorexia which makes plain the appropriateness of poetry therapy for clients in recovery. Expression and communication are important, they maintain, as silence can be a feature of an anorexic presentation; a refusal to speak can be a component of the ambivalence toward treatment and recovery. Poetry therapy works with meaning, like poetry and psychotherapy, and its precise use of metaphor offers a way to reconnect with emotions. It can be less threatening to initially connect with a non-present poet through their writing, circumventing defences, and identification with poems can bring relief and strength. Writing poetry becomes a way of communicating personal meaning, and brings pleasure in accomplishment. Poetry therapy therefore provides indirect access to therapy and facilitates expression, and as it reduces self-censoring or reticence, it increases clients' sense of effectiveness and assertiveness, 'providing a means of transforming into words what is communicated physically through the symptoms of anorexia nervosa' (Woodall & Andersen, 1989, p. 205).

Client report
The first author contacted the second author, a former client, while drafting this paper, and invited her to contribute a written report of her experience of attending a poetry therapy group as part of her treatment. The second author kindly agreed, and, with permission, what follows is in her own words.

My truth
I took part in a poetry therapy group when I was an inpatient in an eating disorders unit. Prior to going into hospital, I had not received any treatment for anorexia. I was at the beginning of a long process, and during my time as a hospital inpatient and day patient, I took part in a variety of therapy groups. Today, six years after I was discharged from hospital, it is the poetry group that stands out in mind as the group in which I could be at my most honest, my most creative, and my most open to possibilities, with multiple truths existing alongside each other.
For me, anorexia has often been an attempt to be perfect, when inside I have always believed myself to be bad. The feeling of badness is not, entirely, rooted in fact or reason, but more a physical sensation. I am intelligent, can apply logical thinking and be incredibly rational. I sometimes feel that there are two brains inside my head: a rational brain which is fully in agreement with all the people, therapists, family and friends around me who repeatedly point out the blindingly obvious -I'm not fat, it's ok to eat, I am a good personand a second brain which does not use words and does not respond to them, but instead uses emotions, sensations, and bodily urges as its weapon. For a long time, I have hated this sensation brain and have tried to cut myself off from everything it demands. Anorexia is my way of coping with the bodily sensations that have no words. Anorexia numbs that pain and takes you to a place where everything is constant and predictable, where everything is level and reassuring; like a fixed metre poem using rhyming couplets, it feels safe.
Therapy sessions like CBT appeal to the rational brain. The problem with CBT is that my sensation brain cannot connect with the words or the logical arguments that CBT presents, and so, when the session is over, the rational brain tries its hardest to stay in control, but ultimately the sensation brain is stronger and wins out. I remain anorexic.
The poetry group takes a different approach. During the group we read poems, such as the series by Gross (1998) about his daughter's anorexia, which describe the reality of how it feels to have anorexia. The poems put the unbearable chaos inside of me into something external, something fixed and on a page. The poems did not attempt to explain anorexia in its entirety and, most importantly, they did not always attempt to challenge the thoughts and behaviours associated with the illness. Instead, the poetry group gave me a space to start to recognise the sensations that for so long I had tried to cut off from and, slowly, to learn that those sensations are valid. Learning to accept and tolerate emotions, sensations and desires is a major part of my ongoing recovery, and I still read and write poems as a way to engage with myself on a level that is rational. Moreover, I read poems when I am in distress, as the rhythm and sound of them soothes the part of me that is hurting, perhaps like a lullaby soothes a child.
During the poetry therapy group, writing poems with other members of the group was also incredibly powerful. Anorexia can be a very isolating illness; you cut yourself off from your own feelings, and that results in an inability to properly connect with other people around you. By writing a poem with the other group members, we were able to create something together that validated our experiences as a group. We created a book of all the poems we made which was kept in the lounge on the ward. When new patients were admitted, I would watch them open the book and read the poems. I hoped, and believe, that the poems offered them comfort as they helped them recognise their own struggles and their own hopes through the words of others.
I do not think that poetry therapy is a replacement for all other therapies and believe that CBT is a much needed strategy for learning to make changes to behaviours, but I do think that poetry therapy offers something that talking therapies do not. As the person reads a poem, they are given the opportunity to engage in that poet's world and in the poet's feelings, which often seems safer than diving straight into your own messy mix of sensations. Poetry therapy allowed me to reach the intangible, the nameless sensations, the silent noise, the core of my illness and the key to my recovery.

The evidence base
For this paper, a literature review was conducted using the terms 'poetry therapy,' 'bibliotherapy' and 'therapeutic writing' in the indexes PsychInfo and Google Scholar, so that research from all related fields which may indicate the potential of poetry therapy could be examined. The majority of these publications were descriptive and employed no standardised research method. A small number of relevant quantitative and qualitative research papers were found, which mainly showed support for poetry therapy as an intervention, with some caveats. Firstly, research from the related area of expressive writing will be outlined, followed by a review of quantitative and qualitative studies of the use of poetry and creative writing for therapeutic purposes.

Expressive writing
There is a sizable amount of research on the therapeutic benefits of the related area of expressive writing, stemming from Pennebaker's (1997) work. Esterling et al. (1999) summarised well this extensive literature, which shows expressive writing to be as effective or nearly as effective as a short-term psychotherapy intervention, based on self-report outcome measures, for clients with minor issues. Esterling et al. (1999) summarised other research which shows that expressive writing is associated with less doctor visits, less days off sick, and improved liver and immune function. Interestingly, some further work has examined change processes, exploring the roles of cognitive change, levels of disclosure and confrontation of events (Esterling et al., 1999). However, the majority of this research has been conducted with healthy university students and over a few sessions only. Greenhallgh (1999), for example, was sceptical of the value of such expressive writing studies, arguing that they overstate the case, are badly designed, and largely miss the point, in that writing therapy is much more of an art than a science.
Most research to date regarding writing and eating disorders has examined interventions which apply expressive writing in the Pennebaker (1997) paradigm in some way to eating disorder symptomatology in non-clinical samples. For example, East et al. (2010) have reported a preliminary trial of expressive writing tasks on features linked to eating disorders in a student sample. The study reported positive results, but employed very small numbers. Earnhardt, Martz, Ballard, and Curtin (2002) also applied an expressive writing task to students, using an inclusion criterion of negative body image markers. Both the control group and the expressive writing group showed improvements, however. The authors offered many ideas as to why this may be, such as the placebo effect, a social desirability effect or pre-test sensitisation. As both the control and the experimental groups were invited to do some writing in this design, another explanation for these results, however, may lie in the effectiveness of writing in general, rather than any particular paradigm of writing intervention. Similarly, Frayne and Wade (2006) compared the effects of a written emotional expression task and a planning task control on bulimic symptoms. Again, both groups showed improvements, which the authors took to indicate a need for further research. Likewise, Johnston, Startup, Lavender, Godfrey, and Schmidt (2010) did not find that an expressive writing intervention offered via email made any significant difference in reducing bulimic symptoms in a non-clinical group, when compared with a control distraction task. The authors argue for more research using qualitative methods to examine the nature of the therapeutic process.
All of these studies also point to the need for more research with clinical samples. Robinson and Serfaty (2008) presented the results from a pilot randomised controlled trial of email therapy for bulimia nervosa and binge eating disorder. Interestingly, they found only a non-significant difference between an unsupported self-directed expressive writing task and therapist administered email therapy for bulimia, which could also indicate that writing in general can be a helpful intervention for clients recovering from eating disorders.

Quantitative research
The majority of the limited numbers of research studies on the effectiveness of poetry as an art therapy intervention follow a broadly quantitative research design, but with very limited subject numbers. Boone and Castillo (2008) used an experimental design to examine the effect of an online poetry therapy intervention for counsellors experiencing secondary PTSD symptoms. The experimental group, which was invited to respond to poetry, experienced more clinical benefit than the controls who were not, as measured by the Impact of Events Scale. Echoing the case material presented earlier, Mazza (2003) documented experimental research by himself and Golden (1995) showing that poetry therapy interventions, and the collaborative creative writing exercise in particular, facilitate important group processes such as advancing group cohesion compared to controlsa factor cited by Yalom (2005) as key to effective group therapy. Lowe (2006) recorded biological evidence of the effectiveness of writing emotional poetry or reading positive poems by measuring levels of an antibody which defends against infection before and after writing and reading. Antibody levels rose after writing emotional poems but not after writing more neutral poems, nor did they rise in the control group who wrote no poetry. Antibody levels also rose after reading positive poems, and not after reading negative or neutral poems. The sample sizes in this study were again small however, and no control group is mentioned in the reading study. Mohammadian et al. (2011) reported a small scale evaluation of a group poetry therapy intervention which involved reading poetry for therapeutic purposes. The poetry therapy group showed significant decreases in their scores on depression, anxiety and stress on the Depression Anxiety Stress Scale compared to the control. In Tegner, Fox, Philipp, and Thorne's (2009) study, a poetry therapy group in which clients wrote individually during the session, shared their work with each other, and responded to each other's writing, was offered to clients being treated for cancer. Their research documents the intervention's ability to reduce anger and the need to control emotions in this client group, but the study again only involved small numbers of participants. Finally, Heimes conducted a systematic review of the evidence for poetry therapy in 2011. Unsurprisingly, he found that existing work, while highlighting both the cost-effectiveness and efficacy of poetry therapy, only fit low levels of evidence as determined by the University of Oxford's Centre for Evidence Based Medicine (CEBM), due to their designs and low participant numbers. He also found that the majority of the existing research was conducted in the US, and that more was needed from elsewhere in the world.

Qualitative research
Heimes (2011) also acknowledged the lack of fit between a systematic review using the CEBM's standards for levels of evidence, and poetry therapy, which may be more suited to qualitative research methods that explore meaning and expression. There have been some qualitative investigations of poetry therapy. Jensen and Blair (1997), for example, explored the tensions between writing for therapeutic purposes and creative writing practice in a community-based writing group for exmental health service users. Mazza (2003) summarised historical research, including case studies and qualitative surveys of staff and patients at hospitals where poetry therapy was offered, which indicate good up-take of the intervention, advancements in group cohesion, particular benefits for withdrawn patients, and that the intervention was less beneficial for those with limited cognitive functioning. Kidd, Zauszniewski, and Morris (2011) presented an interesting piece of qualitative research using grounded theory to analyse interview data collected from carers of people with dementia about their experiences of writing poetry. Emerging themes around the possible experienced benefits included self-affirmation, catharsis of negative emotions and the validation of positive emotions, a sense of achievement, increased acceptance, greater empathy, the opportunity to reflect, greater self-awareness, fun, positive challenge, and an increased energy for helping others, some of which can also be seen in the earlier client report. More recently, Petrescru, MacFarlane, and Ranzijn (2014) collected feedback from four participants after a poetry writing group intervention for clients with early stage dementia. Client feedback on the poetry workshops was overwhelmingly positive, but this exploratory study did not analyse any of this data rigorously.
Naturally, research on poetry therapy and eating disorders is even more limited, perhaps in part due to the difficulty of evaluating interventions in eating disorder treatment programmes with many components (Kaplan, 2002). However, Robbins and Pehrsson (2009) set out a moving case report of an anorexic client responding to published poems in therapy, to good effect.

The need for more research
The chorus of voices in the literature calling for more research on the effectiveness of poetry therapy is overwhelming (Gorelick, 2005;Heimes, 2011;Hornyak & Baker, 1989;Johnston et al., 2010;L'Abate & Sweeney, 2011;McArdle & Byrt, 2001;McCulliss, 2011aMcCulliss, , 2012Schmidt et al., 2002), particularly in regards to poetry or arts-based therapies for anorexia (Kaplan, 2002;Robbins & Pehrsson, 2009). Jensen and Blair (1997) point out that most papers in this area are based on clinical opinion unsubstantiated by evidence. In other words, they present many theories about how this intervention creates its benefits written by enthusiastic advocates, in the face of a dearth of actual research, qualitative or quantitative. Wright and Chung (2001) concurred, and contrasted well the literature produced by artists and writers against those by psychotherapists or other health professionals, in terms of their different emphases, tone and subjects. However, they contended that publications from both are needed, and they note with interest that work from both groups seems to be reaching similar conclusions. Mazza (1993) proposed a research agenda which prioritises qualitative and quantitative process and outcome research examining the effects of poetry therapy on specific groups, and the experiences and perceptions of those who engage in creative writing for therapeutic purposes. Mazza (2003) went on to articulate the ethical imperative for upgrading research on poetry therapy and arts therapies in general, in the service of ensuring that clients have access to most appropriate treatments for their presentations. Nicholls (2009) has gone further, and has criticised the emphasis in the literature on health psychological research and publications on expressive writing, as compared to research on poetry therapy or therapeutic creative writing. Like Heimes (2011) and Johnston et al. (2010), she recommends the use of more appropriate research methods in this work as well, such as phenomenological research methods and other designs that capture the experience of writing. Writing itself could also be used as a research tool or process as part of this work (Nicholls, 2009). Jensen and Blair (1997) set out one primary problem, in that most published papers do not define their terms well. As they could therefore be discussing different interventions, there is a real need for clarity in the field. Mazza (1993Mazza ( , 2003 also emphasised the importance of setting out the detail of the intervention under study, its context, and the presentations to which it is being applied, so that research is transparent and replicable. While there is debate in the field regarding the relative weight of therapist effects and relational factors (Wampold & Imel, 2015) versus standardised interventions tested in controlled trails (Roth & Fonagy, 2005), further quantitative research employing a standardised protocol could bring this intervention to the attention of a wider audience, such as commissioners and service managers.
A replicable model Mazza (2003) offered a group poetry therapy procedure which incorporates all three modes of the RES model and which could be applied to a wide variety of client groups and presentations.
In each session, after a brief opening round, the poem written by the group at the last session is circulated. Group members are invited to read this to themselves in silence, before a volunteer is sought to read the piece aloud in the room, to allow for a different kind of processing of the piece and the therapeutic benefits of reading poetry aloud. Group members are then invited to share their gut reactions to a part of or the whole poem, perhaps in terms of what grabs their attention, what feelings are now arising, what they dislike about the poem or what they would like to change. Their responses are linked by the facilitator to the difficult experiences they are facing, leading to a group exploration of the meaning of change or the lived experience of recovery. At intervals, the group leader or any group member can offer a further piece of published poetry, writing or song lyrics in the same manner, to enable the recognition of their experiences in others, a deeper examination of these, and an application of these insights to their journey (McCulliss, 2011a).
Towards the end of the session, the group leader facilitates a collaborative creative writing exercise, to support the group to collectively write a poem summarising their overall reflections from the session or their relationship to a particular theme which arose, often using an image or metaphor that naturally emerged during the discussion. In typing up this collaborative poem and selecting published poems based on their discussion for next week's session, the group facilitator demonstrates to group members that they are being held in mind collectively and individually in between appointments. Mazza (2003) has offered guidance on poem selection, useful poems, questions to prompt reflections and self-supervision tools in the core text Poetry Therapy: Research and Practice.

Conclusion
Poetry therapy is a promising arts-based therapeutic intervention with clear applications for clients recovering from anorexia. More qualitative research examining rigorously what clients experience as helpful and the process of change is needed. Further quantitative research examining the efficacy and effectiveness of poetry therapy is also needed to evidence whether this approach should be more widely available, and to impact future practice. One interesting body of research involves the use of software, such as Pennebaker's Linguistic Inquiry and Word Count programme or NVivo, to document types of language used and changes in language over time (Esterling et al., 1999;Santarpia, Tellène, & Carrier, 2013). For example, Paul (2015a, 2015b) analysed a poetry therapy intervention using interviews, published haiku, and the creative writing of haiku using the Tropes semantic analysis software programme, and showed changes in language over the course of the intervention that indicated therapeutic change. Finally, a wider, more systematic literature review specifically investigating whether poetry therapy could improve outcomes for clients diagnosed with anorexia nervosa, incorporating more search terms and more databases, could guide future practice, commissioning and research.

Disclosure statement
No potential conflict of interest was reported by the authors.

Notes on contributors
Christine E. Ramsey-Wade, has trained as a counselling psychologist, supervisor and mindfulness teacher, and works as a Senior Lecturer in Counselling Psychology at The University of the West of England, Bristol, where she is a member of the Centre for Appearance Research (http://www1.uwe.ac.uk/hls/research/appearanceresearch.aspx), and in private practice.
Ellen Devine is a public and patient involvement volunteer with the Eating Disorders Health Integration Team led by Bristol Health Partners. She uses her experiences of having an eating disorder and being in treatment to support service development and to highlight the importance of listening to the voices of people who have had or have eating disorders. In this article, Ellen shares her experience of poetry therapy during her treatment for anorexia.