Is training in creative writing a feasible treatment adjunct for clients suffering from chronic alcohol-use disorder?

Abstract

Introduction:

If and how various ways of expressing oneself creatively might help heal and resolve mental problems is a question that has been discussed for decades. Creative writing is typically used as an add-on to traditional therapy rather than being an integrated part of the therapy. There is a lack of research into the effect of implementing creative writing as an add-on to therapy for alcohol dependence. The aim of this study was to introduce creative writing to chronic alcohol-dependent clients.

Method:

A creative writing course was held as a pilot study with six workshops each lasting two hours. Six clients recruited from a harm reduction unit in a Danish alcohol treatment centre and suffering from chronic alcohol-use disorder participated in the workshops. The workshops were led by two professional authors experienced in teaching creative writing. At the end we conducted three interviews: one with the clients, one with the therapist and one with the authors. The interviews were analysed with a focus on the clients’ perspective.

Findings:

In the analysis, we found that writing can give the clients a lower self-esteem, make them fear failure, and it can be too private. We also found that writing can increase the clients’ self-confidence and unity in the group, give them new nuances of life, stimulate their brain, give zest for life, and improve relations between clients and care providers. Further, we identified a few points of importance to be added to the organization of the workshops.

Conclusion:

We found that clients suffering from alcohol-use disorder participating in creative writing profited from increased self-confidence, a sense of unity, were better able to appreciate the nuances of life, experienced stimulating brain activity, had more zest for life, and that the intervention improved relations between clients and care providers.

Keywords

addiction treatment alcohol-use disorder creative therapy creative writing harm reduction qualitative

Using art or artistic tools in therapy is not new. For decades, studies have looked into whether and how self-expression through artistic activities may help heal or resolve mental problems. Several art forms have been tried and for various purposes, not only in mental health settings, but also in treatment of addictions. A survey (Aletraris, Paino, Edmond, Roman, & Bride, 2014) of a representative sub-sample of American addiction treatment programmes showed that 36.8% of the programmes surveyed offered art therapy, 14.7% offered music therapy and 11.7% offered both art and music therapy, in addition to or in lieu of conventional treatment for substance-use disorder (SUD). The survey showed that treatment programmes offering art therapy had a higher percentage of female clients than programmes that did not, and that incorporating art and music into therapy was more common among programmes providing Motivational Enhancement Therapy and 12-step therapy than if other types of treatment methods were on offer (Aletraris et al., 2014).

Developed in the last half of the 20th century, art therapy may include any of the arts (painting, music, dance/movement, drama, poetry, etc.) as treatment (Malchiodi, 2012). In treatment for alcohol dependence, the most common expressive art therapy is incorporating drawing and/or painting into therapy sessions. Here, the basic idea is to introduce clients to an alternative way of expressing themselves as a substitute to speech (Aletraris et al., 2014).

Introducing written words as a therapeutic tool instead of speech is also a method of expressive art therapy. Expressive writing, as developed by James W. Pennebaker in the 1980s, is designed to aid the client to work through traumatic life experiences (Pennebaker, 1997). The clients are asked to write down their experiences, thoughts and narratives, in particular those causing pain. This method does not require the assistance of a therapist; there is no need for preparation or any follow-up work (Gripsrud et al., 2016). Several studies have indicated that expressive writing may be effective in reducing the frequency of visits to a physician. It also has beneficial effects on somatic factors and may reduce pain symptoms (Gripsrud et al., 2016).

Expressive writing is not the only way that writing can be used within a treatment programme. Writing exercises may also serve a purely creative purpose and function as a means to develop writing skills and new ways to look upon the surrounding world in general. In creative writing, the therapist may for instance ask clients to look at works of art and describe in writing the thoughts that come to mind and what they see (Malchiodi, 2012).

Creative writing is mostly used as an add-on to traditional therapy rather than as an integrated part of the therapy, since it is, in fact, not therapy. To our knowledge, no studies have so far described the effects of implementing creative writing as an add-on to therapy for alcohol dependence. We were curious to know whether creative writing exercises might be a meaningful add-on to therapy for alcohol dependence, also because creative writing, contrary to expressive writing, does not involve describing feelings or even very personal matters. Previous qualitative studies have found that some men feel uncomfortable in therapy and tend to feel as if they are put under a microscope (Søgaard Nielsen, 2004). We wondered whether adding creative writing to therapy might serve as a pleasant and meaningful exercise.

In Denmark, treatment for alcohol dependence is offered free of charge. It is the responsibility of Danish municipalities to make treatment available to local citizens, who may remain anonymous during treatment if they so choose. In Denmark, outpatient treatment is the most common treatment form (Sundhedsdatastyrelsen, 2016), and the most common psychosocial treatment methods are motivational interviews, cognitive behavioural therapy and family therapy. Most treatment courses are performed as individual therapy or group therapy. The psychosocial therapy may be supported by pharmaceutical treatment, typically disulfiram or acamprosate (Becker, 2016).

We designed this pilot study to test the feasibility of creative writing as an approach to support the treatment of chronic alcohol-dependent clients. We wanted to investigate how creative writing was received by the clients and whether, by offering training in other ways to express themselves, creative writing could increase clients’ self-esteem and broaden their perspectives on their surroundings. Creative writing was introduced to a small group of chronic alcohol-dependent clients in a harm-reduction unit in a large Danish alcohol treatment institution. The creative writing programme was organised as six two-hour workshops, and the instructors were two renowned professional authors experienced in teaching creative writing. The writing exercises did not involve alcohol-specific topics at all. The creative writing did not have any therapeutic function per se, but instead aimed to offer the clients new experiences and self-insight through working with words and texts. The creating writing programme was developed particularly for learning how to write fiction (Llambías, 2015) in order to give the clients means to widen their perspective on life in general and to offer them training in alternative ways of looking at, reflecting on and expressing themselves.

Aim

We wished to investigate whether clients suffering from severe or even chronic alcohol-use disorder (AUD) would want to participate in a creative writing course and whether they thought participation was helpful, gave them pleasure and whether they perhaps experienced an improved outcome of the alcohol treatment they received parallel to the creative writing course.

Method and material

Setup (writers, etc.)

The creative writing course was arranged from January to March 2016 with six workshops, each lasting two hours, once a week. The course was offered as an addition to a harm-reduction programme unit in the Alcohol Treatment Centre in a larger Danish city. The clients who were offered the course had finished their structured outpatient treatment for AUD, and were either in need of long-term flexible support or unable to manage participation in structured outpatient treatment. They were thus about to commence a long-lasting outpatient support programme. The harm-reduction programme unit offered social support and activities, individual and group sessions, flexible opening hours and easy access to the healthcare staff at the treatment centre. The harm-reduction unit was open three hours a day, four times a week, and clients were allowed to stay there and work during opening hours or stay in the garden of the harm-reduction unit outside opening hours. The harm-reduction unit was housed in a building adjacent to the main building of the Alcohol Treatment Centre.

The creative writing workshops took place in a meeting room in the building housing the harm-reduction unit. The workshops were organised and taught by two professional authors experienced in a wide range of literary genres. The authors led the creative writing workshops either individually or together. They had no experience in alcohol treatment, and no particular knowledge about AUD. An alcohol therapist (social worker by training) was present during each workshop together with a trainee halfway through her training as a social worker. In addition, one of the researchers (RH) participated in workshops 4 and 6, mainly to observe and get a sense of what transpired in the creative writing workshops. In total three researchers worked with the evaluation of this pilot study. The content of the six workshops is described in Figure 1. The exercises in the workshops were chosen by the authors and planned based on the authors’ experience and what they found appropriate and in accordance with the clients’ writing skills.

Figure 1.

Content of the six workshops in the writing course.

Ethical considerations

Since creative writing exercises may evoke strong feelings, we chose to invite the therapist and her trainee to participate in all the workshops. Thus the authors were free to concentrate on the writing exercises, knowing that the therapist was available to support the clients if necessary. Taking an active part in the writing exercises was voluntary for the therapist and the trainee, but they decided to carry out the writing exercises along with the clients.

During a typical workshop, the authors introduced two to three exercises in creative writing to stimulate the clients to write a short text, asking them, for instance, to “describe a topic, but avoid using the following words”, and/or using techniques such as “cut-up” (Jones, 1965). The clients were encouraged not to worry about grammar and spelling. After each exercise, the texts were read out loud. It was always up to the clients to decide whether or not they wanted to carry out the exercise, and they could also choose whether they wanted to read aloud what they had written. The exercises were designed to offer freedom of writing, paradoxically by setting various restrictions. In general, the main idea was to get the clients started on writing short texts. Usually everyone present in the room during the workshops participated in the exercises, including the clients, the authors, the therapist, the trainee and the researcher.

Because the study involved a non-invasive addition to treatment and because participation was open to all clients in the small unit who wished to participate, approval from the local ethics committee was not required. No randomisation or follow-up interviews with clients were carried out. All guidelines for data protection were followed. All procedures in the study are in accordance with the second Declaration of Helsinki (World Medical Association, 2013).

Recruitment and participants

In this study, clients were recruited from the harm-reduction unit. To recruit participants among the clients, the two authors and two researchers visited the harm-reduction unit to inform the clients about the creative writing course three weeks prior to its start. An information meeting for the clients was held before the participants signed up for the course. There were several reasons for the extra meeting: (1) to explain once more, in depth, about the content of the workshop, and, in case of regret, to offer the clients an opportunity to withdraw their consent to participate; (2) to advise about the framework and organisation of the workshops, for instance stressing the fact that the clients would be allowed to skip exercises if they preferred, and so on; (3) to give the authors a sense of what to expect from the clients; (4) to give the authors an idea of the clients’ background and writing skills; and (5) to emphasise confidentiality, making sure the clients felt completely safe and comfortable sharing texts with the group, perhaps about personal experiences. The clients were told that participation was entirely optional and completely unconditional. A total of five clients participated in the six workshops: two women and three men, all Danish, Caucasian and with a mean age of 52 with a range of 40 to 66. Two of the clients lived on social security, one worked in part-time supported employment, one was on invalidity benefit and one qualified for state pension. One client had the equivalent of a master’s-level education, two had bachelor’s-level education and one was a trained craftsman. The clients had suffered from alcohol dependence for 13 to 33 years (on average 20.6 years). They had been in treatment between once and four times prior to the present treatment course (in addition to numerous detoxifications). Compared to the average client seeking outpatient treatment for AUD, the clients had been assessed by the treatment institution as suffering from fairly severe problems, both in relation to alcohol and in terms of social functioning.

Data

In order to collect more data for the evaluation of the creative writing course, a closed Facebook group was set up, open to the authors, therapist and researchers only. After each workshop, the authors posted the content of the day’s workshop, their reflections on the day’s programme, and noted if there was anything they might want to adjust in the next workshop. In addition, the therapist posted updates on how she experienced each workshop. The Facebook updates never contained any personal information about the clients. In this article, data from the Facebook updates have been used as a supplement to the data from the interviews. The Facebook group was deleted upon completion of the data collection.

When the creative writing course was completed, three interviews were conducted: one group interview with the clients, one group interview with the authors, and one individual interview with the therapist who took an active part in the creative writing course. The researchers’ focus during the interviews was to discover how the creative writing course had been received and experienced, whether or not it had felt pointless and/or resulted in new experiences that might be helpful in the long run. In addition to evaluating the present course, the informants were asked what they felt should be taken into consideration if the creative writing course were to be implemented on a larger scale in the alcohol treatment centre. The first focus-group interview, with the clients, was carried out right after the conclusion of the creative writing course as was the individual interview with the therapist. The interview with the authors took place one week later. All interviews were audio-recorded and moderated by an experienced interviewer and researcher (ASN), who had not attended any of the workshops nor been part of the Facebook group and was therefore unbiased. One researcher (RH) participated in all the interviews and contributed with questions at the end of the interview.

Analysis

Before analysing the interviews, RH transcribed the audio files from the three interviews and SLJ merged the Facebook updates into one document. The main focus of the analysis was on the clients’ thoughts on creative writing and their experiences from the workshops, positive as well as negative. In addition, we wished to include observations from the therapists and the authors and take them into account.

We carried out a systematic analysis of the qualitative data by means of a General Inductive Approach, often used in evaluations based on qualitative data (Thomas, 2006). The General Inductive Approach presumes that the analysis of data is guided by the evaluation objectives – in this case the clients’ experiences from the workshops – and that the findings arise directly from the raw data – in this case the transcribed interviews. The outcome of analysis is usually a model or framework summarising the raw data, key themes and processes (see Figure 2) (Thomas, 2006).

Figure 2.

Findings. Three negative and six positive themes were identified from the interview with the clients.

First the documents of transcribed text were read carefully several times by the researchers, and the statements most relevant to the research objective were identified. In the next step, the statements were grouped into themes. The process of re-reading and merging into themes continued until all statements had been placed in themes and the themes were fully defined. In the results section, we present the merged themes, using quotations from the interviews as illustration.

Findings

The analysis of the interview with the clients identified three negative and six positive themes. The three negative themes were: (1a) Low self-esteem, (2a) Fear of failure and (3a) Too private. The six positive themes were: (1b) Self-confidence, (2b) Unity, (3b) Nuances of life, (4b) Stimulating brain activity, (5b) Zest for life and (6b) Improved relations between clients and care providers. From the Facebook updates and the interviews with the authors and therapists, we also identified some other important points. The overall themes are presented below.

Negative aspects of the creative writing course

Although prompted directly about negative aspects of the creative writing course, the clients did not report directly negative experiences. They said that they had felt somewhat uncertain at the beginning of the course, and further described how they had felt slightly worried beforehand because it was such a long time since they had done any writing at all. Because of this uncertainty, it was important to them that the authors continuously stressed that it did not matter how they wrote or what they wrote about and also that they could always skip specific exercises. The clients’ initial concerns are described in detail in the following.

(1a) Low self-esteem

All clients had felt challenged when writing, in particular at the beginning of the course, and this became particularly evident when two of the clients came forward and put their feelings into words. One client said: “I realised that I’m just not very good at this…Well, perhaps it’s just that I’m not very good at putting words together when it’s in writing”.

The same two clients concluded that during the course they felt their self-esteem had improved. However, one of the other clients protested and said “on the contrary” when asked individually whether they had experienced increased self-esteem. Nevertheless, the same person also claimed that he did not regret participating, and that he had found it “quite interesting”.

(2a) Fear of failure

All the clients described how they had worried about failing, in particular at the beginning of the creative writing course. One client described writing as “anxiety-raising”, as it was several years since he had written anything other than post-it notes and job applications. A client who claimed to be a “bit of a perfectionist” described how his fear of failure at the beginning of the course had led him to obsess about the grammar and spend most of his time checking if, for example, the commas were placed correctly. He continued:

[O]ne of the problems I struggled with was that I’ve always been a bit of a perfectionist. So I would focus on grammar and all that. Wanting to be certain that everything was correct. But the authors managed to tone down that fear, like – well it doesn’t matter that much. Because as Trisse [author] said – I always leave that to my publisher. She’s not very good at commas and grammar either. So there was no need for us to worry about that either.

Although this client was aware that it was more about processes inside his head and that what mattered was really just writing something, the concern was still something he found difficult to put aside.

(3a) Too private

One of the clients felt that some exercises had been close to overstepping his boundaries. To him, these exercises implied sharing stories that were too private:

Some of the others, they’re very open, almost pouring their hearts out. Well, I would never do that in a group like this. No way, NEVER EVER.

He later described how he found intimate memories or childhood anecdotes especially difficult to share in a forum like the creative writing workshops. It should be noted that, towards the end of the interview, another client stressed that it had been voluntary and entirely up to each individual how much they chose to share in the group. All clients were fully aware that the creative writing workshops did not have an alcohol-reducing aim, and the clients who expressed reluctance to share memories also stressed that they had found other types of exercises interesting and quite fun.

Positive aspects of the creative writing course

(1b) Self-confidence

The most prominent positive finding was that the clients felt they had gained more self-confidence and self-esteem through the course, and ascribed this to the writing exercises. They also reported an increased belief in themselves and their own abilities. A participant said that although at first she felt stressed, she gradually re-discovered forgotten competences, concluding that “you realise it isn’t that dangerous after all. You just have to throw yourself into it”. This client felt that the new positive experiences contributed to strengthening her self-esteem. Another client said:

Well, [the creative writing] was actually somehow reassuring, comforting even, because I found that I was actually still able to write. The more you got into it, the less rusty you felt, and the more comfortable you felt about it.

This quotation illustrates how the client felt a progress from feeling insecure to gaining more and more confidence in herself the more she wrote during the course. The workshops also included the clients reading their texts out loud to each other. Some clients feared this would make them feel insecure, but when they experienced recognition and understanding from the other clients, they felt that reading aloud added to their self-esteem and self-confidence. Reading aloud felt completely strange in the beginning, since as an adult you are rarely asked to read aloud to anyone, as one of the clients put it. Some of the clients’ interest in writing and reading grew throughout the course, and in the end some even considered taking up reading novels or thought about educational options.

(2b) Unity

All clients agreed that the creative writing course had strengthened their sense of unity, of being a group. One compared it to going to work: participating in the creative writing course made getting up in the morning worthwhile, as did the knowledge that other people were expecting you and relying on you to turn up. Furthermore, the clients felt that the workshops gave them an opportunity to discover new aspects of themselves and others through the stories and memories that emerged during the process; insights that ordinary conversations or situations would not have evoked. One client said that he simply loved hearing other people’s stories. Also, the creative writing course felt meaningful to the clients because, as one client expressed it, you didn’t just sit around talking about what you did yesterday. In the workshops, you discovered more nuances about the other clients’ lives and heard all these small stories you would normally never get a chance to hear. This helped the clients create a sense of community and provided reassurance. As one client described it:

Here [in the workshops], we didn’t meet as alcoholics. Here we met simply as people.

Instead of alcohol and related problems, the central issue of the course was creative writing. Consequently, the clients felt that, compared to the traditional client–professional relationship, in the workshops they, the therapist and the authors were together as equals.

(3b) Nuances of life

When the clients were asked to describe what they had gained from the six workshops, some mentioned rediscovering good memories they had almost forgotten, and that the workshops had helped them gain a more nuanced picture of, for instance, their childhood. One client explained how a series of sessions and conversations with professional therapists during his treatment had focused only on the difficult things in life. In contrast, the creative writing exercises had brought back some of the pleasant experiences from his childhood. Because of the creative writing exercises, he now realised that as a child he had actually experienced some “incredible and exciting things”, which he had almost forgotten.

One client explained how he felt that the creative writing course had helped him get a broader perspective on life, which had also helped him become aware of its opportunities.

Well, it sort of got me to take the helicopter view and look down on my life, and then I realised that, well hey, there’s actually a lot of pretty cool opportunities out there, and they are open to everybody. I mean, it could just be really appreciating the smell of, say, a good cup of coffee.

The enjoyment of freshly made coffee, as described above, was not a direct effect of the course, but it shows that the client’s interpretation of his surroundings, his appreciation of the small things in life, had changed and widened. Several of the clients felt that things or experiences that had been there all along were now seen as contributing to the value to life, and the clients ascribed this realisation to the creative writing course.

(4b) Stimulating brain activity

All the clients agreed that the creative writing course had acted as a platform for contemplation and reflection. They felt that the weekly writing workshops had given them an opportunity to explore the facets of language and its many uses. They also said they were fully aware that the creative writing course had taken place during a period of their lives when they were sober and hence had the resources and energy to make the most of it. A client explained that he had been a bit worried beforehand whether he still had the mental capacity to reflect and use his brain in general. Participation in the creative writing course had made him realise that his brain still functioned:

Actually, I’d been a bit anxious that my brain was ruined or my mind so dulled that it would be impossible to ever wake it up again. But now I feel it’s a bit like being back at school, you pick up things and learn as you go along.

Throughout the course, the writing exercises offered the clients opportunities to recall and re-examine memories primarily through their senses. For instance, the clients were asked to recall a situation they had been in, and then describe the sounds they heard, the temperature of the room, the taste of things and so on, and how it affected them. Such exercises led the clients to observe and describe the situation in their own words, and to focus and sustain their attention to the surroundings. The clients felt that the creative writing course became a place where “the imagination was allowed to run free”, giving them an opportunity to think differently, turn things upside down. Some clients expressed that the creative writing course had served as an opportunity to think about something else; a welcome distraction. The distraction was achieved partly because they were given specific tasks in each workshop; tasks that were fun and could be solved in different ways, with no right or wrong result.

(5b) Zest for life

Two of the clients described how they experienced a greater appetite for life and a desire to get more out of it after the course.

Yes, it’s given me a little more courage, courage to perhaps explore life a bit more. Instead of, well, in some cases, at least in my case, I’ve sort of tended to give up beforehand and resign myself to a life in isolation. This [the workshops] has helped me a lot, it really has.

This quotation illustrates how the creative writing course had helped the client to move on, away from isolation and loneliness. Another client described how tedious and monotonous everyday life in the harm-reduction unit could be. But participating in the creative writing course had been more than just a way to pass the time. Some clients also said they had rediscovered old interests and hobbies, like painting or writing, and wanted to take them up again.

(6b) Better relationship with the therapists

Another aspect of the creative writing course shared by the clients was a favourable perception of the presence of the therapists during the workshop. All clients agreed that this presence had been positive and contributed towards “humanising” the therapists. A client described it like this:

I think it was good that they were present because it gave us a chance to get to know them [the therapists] in a different way. I mean, if you think about it, they know practically everything there is to know about our life story, but we really don’t know anything about them. In this course, they suddenly became real people. Instead of just professionals.

By giving the clients a chance to discover new aspects both of themselves and of the therapists, the distance between the therapist and client was reduced. One of the clients also said that he felt the presence of the therapists to be reassuring not only during the course but also afterwards, indicating that the relationship had been strengthened. One of the therapists participating in the workshops described how she discovered that the text she had written was very similar to a text written by one of the clients. This experience led to mutual recognition, and she felt that the event had helped them acknowledge each other as human beings, rather than just professional and client. One of the clients added that after joining the creative writing course, he felt it had become “nicer to come in here [in the treatment programme]”, suggesting that the lines between therapists and clients had softened a bit.

Comments from the authors and the therapist

The following points and observations were extracted from the interviews with the authors and the therapist, and the Facebook updates.

Comments from the alcohol treatment therapist interviewed

Overall, the therapist was very positive about the creative writing workshops: “This has been so interesting and exciting, and great fun to be part of”. The therapist also described that she had been slightly worried in advance about how much privacy to share with the clients during the course. She concluded that it would have to be up to the individual therapist to make that decision. She added that she and the trainee had experienced a decrease in this concern as the course progressed. According to her, the therapists presumed that sharing private thoughts and experiences with the clients had not affected their role as professionals afterwards.

The therapist interviewed felt that her main role as well as that of the trainee therapist during the creative writing course had been to function as support for the clients. Being an experienced therapist, she knew the clients quite well from the treatment and harm-reduction unit, and was able to offer support if the matters brought up during the workshops upset the clients:

And of course there is the fact that I know them from a different context [than the authors]. Well, that’s an advantage because if I know there are some things they struggle with, or find difficult to talk about, then I can support them and help them get things said.

The therapist also found that she could contribute factual information about alcohol to the dialogue, if and when that came up in the workshops. Alcohol was specifically not a central theme in the writing exercises, but obviously it did come up once in a while.

Comments from the authors

In the interview, the authors highlighted some aspects they found important. First of all, they stressed the importance of making sure that the clients knew what the creative writing course involved, and in particular what it did not involve. As stated earlier, we held an information meeting before the first workshop to make sure that the clients were well informed about the project.

Another aspect highlighted by the authors was the importance of making it very clear that there was no need for the clients to worry about correct grammar and punctuation when writing their texts and no need to use difficult words or special words only understood by professional authors or academics. The first workshops had taught the authors that it was really important to explain the tasks to the clients in a very clear and down-to-earth way in order to avoid misunderstandings. As the creative writing course progressed, the complexity of the tasks gradually increased to reflect the clients’ progression. Furthermore, the authors underlined the importance of affirming the positive aspects of the texts produced by the clients, instead of aiming at giving feedback on how the text could be improved.

The authors noted that exercises involving the clients themselves (self-exercises) were challenging for several reasons:

[I]f you’re not used to writing, it can be a huge challenge to write “I….” Both in a good sense that all of sudden you get a chance to put something honest in writing about how you think and feel, and in a not-so-good sense if it blocks you from throwing yourself into the exercise.

At the same time, both the authors and the therapists found the most growth evident during the “self-exercises”:

[Y]es, you may have lived a long life as an alcoholic, but once upon a time you were also a little boy sitting in a greenhouse, inhaling the scent of tomato plants, listening to the rain drumming on the roof. Although it can be a challenge to write about your personal life, and it certainly is necessary to work with other types of exercises in between, this [the self-exercises] is where things start to happen – at least that’s my experience from the times I’ve taught them [the clients].

Comments from the researcher

As mentioned above, RH participated in two workshops in order to observe, get a sense of the atmosphere and assess the interaction between clients, authors and therapists. While observing, RH also participated in the workshop and carried out the writing exercises. During the workshops, RH noted that there was a very high degree of respect between the clients, therapists and the authors. The atmosphere was pleasant, light and serious in the sense that that there was laughter and fun, but also a willingness to try it out and complete the exercises. The participating clients were respectful to one another, curious and interested in discussing the written texts. It was interesting to observe how relations between the clients and the therapist changed during the workshop; in particular it seemed that the exercise involving general childhood memories functioned as an eye-opener for both groups and made them realise how much they had in common.

Discussion

Ours was a pilot study of offering a creative writing course to clients seeking treatment for alcohol-use disorder (AUD), in particular clients suffering from fairly severe social and alcohol problems. The aim was to investigate the clients’ willingness or reluctance to participate, and whether, or how, they felt they benefitted from participating in such writing exercises. Since not all pilot studies are reported, we cannot establish whether a similar study has been conducted previously. By doing a pilot study we have been able to evaluate the recruitment, content and implementation of the workshops. The limitations of a pilot study are testing efficacy and effectiveness (Leon, Davis, & Kraemer, 2011).

The subsequent focus-group interview with the clients indicated that creative writing may – broadly speaking – lead to increased self-esteem, broaden perspectives of life and offer clients an opportunity to experience their surroundings in a more nuanced way. The creative writing course was offered as an add-on to alcohol treatment, rather than as an integrated part of therapy. The course did not focus on alcohol or on solving problems, as treatment usually does. Instead, the creative writing course served as a reservoir for development of resources, ideas, perspectives, fun and recollection of happy memories. Obviously this in itself does not supply the clients with specific tools to tackle their alcohol problems or social problems, but according to the clients in the creative writing workshops, it supplemented the primary treatment positively and helped them regain a feeling of themselves as human beings rather than as alcohol-dependent clients. They also felt that it stimulated their “brain function”.

This is interesting. On the surface, it seems that the clients primarily had fun and enjoyed the writing; at least as soon as they realised they did not need to worry about grammar and punctuation. However, the clients indicated that the experiences from the creative writing course were more than just fun; the course comprehensively affected their life, their perception of it and their interpretation of their surroundings. The course made them aware of life’s opportunities in a broader sense.

The findings suggest that adding a creative writing course to the treatment offered for alcohol-use disorder may be one way of strengthening clients’ ability to live without drinking, at least for those who are willing to participate. Traditionally, treatment for alcohol-use disorder focuses on identifying situations where clients are at risk of starting drinking and aims at developing strategies to prevent drinking. In other words, treatment focuses on controlling emotions and impulsivity, and encourages rational thinking. Contrary to this, exercises in creative writing are not at all aimed at identifying problems, discussing problematic situations or assessing whether or how it is possible to act differently. Instead, creative writing offers training in seeing nuances, having fun with words, using your senses and interpreting your surroundings, with no particular objective other than focusing on the specific thing or topic you are describing. In addition, engagement in artistic activities – as an observer of art or creator of one’s own art – seems to affect the mood, emotions or other psychological states and have a great impact on physiological parameters (Stuckey & Nobel, 2010). While alcohol-focused therapy focuses on introspection and how you react to cues and triggers, creative writing pays attention to and describes what is outside and around you. Although it is a very personal activity, creative writing may be a means to moving clients’ focus away from themselves, towards the outside world, training their ability to perceive, talk and write about the world, compared to other types of therapy that can be likened to putting yourself under a microscope (Søgaard Nielsen, 2004). Hence, it can at least be hypothesised that adding creative writing to traditional treatment may complement the treatment in a way that helps prevent relapses and perhaps even strengthens the desire to embrace a sober life. Experiencing success and developing new perspectives in other areas instead of merely focusing on conquering the craving for alcohol may increase client’s ability to stay sober.

It is an open question whether the therapists present in the workshops should participate in the creative writing exercises on equal terms with the clients. We chose to involve the therapists, and it was a thought-provoking finding that during the workshops the clients felt that they got to know a different side of the therapists and consequently felt more equal to them – realising that therapists were in fact also human beings. The therapists, too, felt that they gained a more nuanced picture of the clients. None of the therapists felt that participating in the exercises had a negative influence on the therapist–client relationship. Neither clients nor therapists said that having participated together in creative writing workshops negatively affected their working relationship or threatened the professional authority of the therapists in the following therapy sessions. Adding this type of activity to AUD treatment could perhaps help overcome the risk of clientisation.

We also found that the clients expressed feeling a higher degree of unity during the writing workshops. This is food for thought and suggests that such workshops may even act as a form of training in social network in a trustful setting. In clients who have suffered from alcohol-use disorders for many years, the feeling of belonging to a group that does not focus on alcohol may perhaps be transferable to other settings of their lives and may thereby strengthen relationships with family, colleagues and new acquaintances. The positive lessons learned from this study allow us to believe that it is relevant to look into the possibilities of adding creative activities to traditional AUD treatment. In this study, we used creative writing, but maybe other kinds of creative activities, like painting, music, or drama/reading groups may serve just as well. We believe that the important aspect is to allow for creativity and evolvement of broader perspectives in a setting that moves the focus away from the client’s alcohol problems and instead develops and supports the other qualities that the client possesses. Obviously alcohol issues may be discussed should they arise in this context, but they are not in focus, as they are in therapy for alcohol-use disorders.

If treatment centres wish to implement creative writing as a supplement to therapy for alcohol-use disorders, or if anyone wants to investigate this further, we recommend taking into consideration the following points: first, it needs to be considered carefully how the workshops are organised and which sort of clients should take part. Should it be clients in regular treatment or clients in long-term treatment programmes like in this pilot study? If therapists are not just present but take an active part, they need to consider how to protect their privacy because it is easy to get carried away in the excitement of writing, perhaps to a point that puts professionalism at risk. Just as the clients are free to decide what to reveal and what not to, a therapist needs to consider carefully the boundary between being a participant on equal footing and being a caring professional. Another point to consider is who to put in charge of the creative writing workshops. In our study, it was professional authors, and this was a success. The clients felt excited and flattered because professional writers from a prestigious Danish creative writing academy dedicated their time to teaching them, and they felt inspired by the authors’ professional competency and extensive experience. The clients understood and appreciated that they were not professional therapists. Experience from our study also stresses the importance of supporting clients during the workshops, to make sure nobody feels too stressed or left out, or that they are not good enough and end up losing instead of improving their self-esteem.

We need more knowledge before we can conclude whether clients suffering from chronic alcohol-use disorder benefit from training in creative writing. We therefore suggest further studies, including longitudinal design supported by qualitative interviews or randomised controlled trials (RCT), comparing the outcome from a group receiving training in creative writing with a control group receiving no such training. For example, an RCT would make it possible to investigate whether the clients decrease their alcohol consumption, whether there is an increase in brain activity and whether the clients’ quality of life improves after participating in a creative writing course.

Strengths and limitations

The strengths of this study are that, to our knowledge, it is the first of its kind in Denmark, and the fact that we brought in two professional authors to lead and facilitate the writing course – both experienced in teaching creative writing. An additional strength is that we tested the creative writing workshops in a real-life setting in a treatment institution and with clients already receiving treatment there. Our study is, however, a pilot study only and hence has several limitations. First of all, the study sample was small and consisted only of clients with a long history of AUD who were recruited from a harm-reduction unit. Therefore we cannot predict to what extent clients from an ordinary alcohol treatment programme would benefit from similar training. A selection bias for the results in this study could be the clients’ voluntary participation. They could be more committed to the project than other AUD clients. Another limitation is that only one interview with the clients was carried out, and this was done immediately after the last workshop, which is a relatively short follow-up period. This may have affected the results since the clients were very excited right after the last workshop. Future studies should apply a longer follow-up time and examine whether, after a while, the clients feel the same level of excitement. A general limitation of focus-group interviews is that clients may withhold important information that would have been voiced in one-on-one interviews (Kvale & Brinkmann, 2013). However, we felt that the clients were trustful of each other, and gave negative as well as positive information in the interviews.

Conclusion

In this study, we found that clients suffering from AUD who were offered training in creative writing felt that they profited from the training in terms of increased self-confidence, sense of unity, a more nuanced view of life, stimulation of brain activity and an increased zest for life, in addition to improved relations between clients and therapists. Therefore, it seems worth considering offering training in creative writing as part of the treatment for AUD, but further studies in this area are needed. We suggest further studies on adding training in creative writing to treatment for AUD on a larger scale in a longitudinal design supported by qualitative interviews and observation.

Footnotes

Acknowledgements

The authors of this article would like to thank the staff at the alcohol treatment clinic in Odense Kommune, the professional authors, Trisse Gejl and Julie Sten-Knudsen, who took part in this study, and Professor Anne-Marie Mai, University of Southern Denmark, who was the originator of this project.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The project is financed by the NICE Welfare project at University of Southern Denmark.

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