These women blew me away.
The (mainly) women in the inpatient psychotherapy groups for clients recovering from anorexia that I led for several years were strong and fierce, determined, with visions and dreams. After all – anyone who can consistently deprive themselves of the sustenance their body is calling for, must have a spine of steel! And when I witnessed those women turning that determination and energy away from their eating disorder and towards their life goals… they were unstoppable.
I also saw that many felt unsatisfied by the treatments on offer, and re-admission rates were high. Clients reported sometimes feeling that the necessary focus on weight gain reduced them to numbers on a scale.
I felt a responsibility to explore and research a wider variety of therapeutic interventions for people recovering from eating disorders, to ensure that they had access to the widest range of options possible.
I was lucky to be given the freedom to set up and lead a poetry therapy group on the ward for many years, alongside the cognitive-behavioural therapy (CBT), art therapy, cooking classes and other support they received during their stay. It wasn’t for everyone, but for some, it was a real game-changer. Because poetry is intuitive, liminal, and non-linear, the group became a space for all their changing experiences, just as they were, in all their contradictions.
I wanted to capture some of their work and share it with colleagues, to increase the availability of these spaces, but my first attempt at a service evaluation was limited. I conducted some qualitative interviews with some ex-clients, but finding space for myself to analyse and publish their words, in a busy life as a parent, trainer, therapist and researcher, has been difficult.
Fortunately, one of my ex-clients agreed to collaborate with me, and we co-wrote a service user report and initial literature review of poetry therapy for clients recovering from anorexia, which was published in 2018.
This made me curious about the evidence base for this type of intervention. Was poetry therapy an effective intervention for anorexia?
I decided to conduct a systematic review, to try and answer this question definitively for myself. But, as soon as I began the laborious and rigorous process of sifting through the evidence that is required for a systematic review, I realised – I was not going to be able to answer my question. The research just hasn’t been done.
So, I decided to widen my net, to ensure I caught something that was still interesting, if not what I expected. I changed my research question to look at all kinds of writing for therapeutic purposes, for all types of eating disorders or disordered eating.
This soon highlighted the range of ways in which writing can be therapeutic. Many studies have examined Pennebaker’s expressive writing protocol, for example, as a well-defined intervention somewhere between journaling and free writing, to externalise and exorcize the demons of traumatic memories. Other, third-wave cognitive-behavioural interventions such as compassion-focused therapy regularly invites clients to develop a more compassionate relationship with themselves through letter writing. And other researchers noted how creative interventions like poetry therapy often worked best in groups, where hearing and sharing words together strengthened the individuals and the group at the same time.
The results, like a good poem, were messy. For example, some studies assigned participants to an expressive writing group and an active control group who also did some writing. However, rather than writing about distressing past events, the control group participants were invited to write about something more neutral, such as the room they were sitting in. These studies often found that participants in both groups experienced improvements in body image perception, body esteem and reductions in disordered eating.
This reminded me of research by Stice and others on The Body Project, who used expressive writing as an active control, and also found small, non-significant benefits in the control group as compared to an assessment-only condition, which were maintained three years after the intervention.
In a way, this shows us how much we don’t know about the power of writing. Does writing help because it distracts us from our difficult feelings and thoughts? Is it another form of exposure therapy; does writing about our eating disorder over and over again in our diaries, for example, lead to these words and thoughts losing their power over time? Or, does writing help us to express and process difficult feelings and thoughts, so that we can finally stop carrying them around?
The qualitative studies that I included in the systematic review gave more clues around possible mechanisms of change. They converged on the importance of expression – of the cathartic benefit of simply sharing our thoughts and feelings, with the page and with each other.
However, even after widening my net, I was unable to conclude that therapeutic writing either was or was not an effective intervention for disordered eating. There were some strong studies indicating that expressive writing around body image could, for example, improve self-esteem amongst university students. But mostly, the results were mixed and equivocal, with a lack of diversity in the samples and a focus on student populations rather than eating disorder service users.
Still, there was enough here to conclude that clinicians can incorporate writing interventions into their care cautiously, ensuring that such moves are tailored to their clients’ needs, interests and preferences – and to encourage other researchers to continue to explore therapeutic writing for disordered eating.
So, for example – clinicians may choose to integrate poetry therapy exercises into their sessions to enhance mood through creativity, or to facilitate the articulation and acceptance of complex emotions. Those leading group sessions on an eating disorder inpatient unit may also choose to do so to enhance group cohesion – a key factor in effective group work. Such exercises could include reading and responding to a poem in a session, or inviting clients to journal or write their own poetry outside the session and then explore this in the therapeutic process.
Unfortunately, it seems that reading and writing for therapeutic purposes, like other art therapy interventions, remain starkly under-researched compared to their more cognitive cousins in the family of psychological interventions. No doubt the challenges of research bidding and grant funding, alongside all the other demands on the time of academics and clinicians, are part of this.
For my part – I still hope to find the time or get the grant to help me to write up those interviews one day! And I hope to continue to build networks with my colleagues in the humanities and the arts, to explore how different forms of reading and writing can induce beneficial mental states – particularly for people recovering from eating disorders.
Meanwhile, I am also working to produce data on other liminal and experiential interventions for disordered eating – mindfulness-based interventions. As a registered mindfulness teacher in the UK, I completed training last year in an 8-week mindfulness protocol called Mindful Eating – Conscious Living™. I am now delivering this programme in the UK as part of a non-randomised controlled trial of mindfulness for disordered eating.
Translating therapeutic interventions that create their impact through the body or through the artistic, creative aspects of ourselves into scientific evidence is very challenging – but I feel blessed to be able to join the many others who are, as my client wrote, trying to ‘reach the intangible, the nameless sensations, the silent noise, […] the key to … recovery.’