Those who go into medicine are often highly conscientious, perfectionistic, and passionate about change. We are selected for our ability to maintain empathy while thinking critically. We are trained to perform a thorough yet efficient interview and exam, craft a differential, declare our assessment, and put a plan into action.
What we are not trained to do, though, is titrate our compassion or withstand the deluge of horror and suffering that comes with truly listening to our patients. To survive as a trainee, intellectualization and compartmentalization become paramount, and we are often praised for wielding these defenses, like perfectly calibrated machines, in order do good work without crippling under the burden of humanity. But we are not machines, and learning to integrate our own humanity into this process is the only way to stave off that fate and embrace the wild and precious life that medicine has to offer us all.
As I look back on my medical training to date, there is one tool that has helped above all on my journey towards integration: the written word. Writing has always been part of my personal practice. However, when I was a second-year resident, I was awarded a scholarship with the expansive goal of exploring the written word in outpatient psychiatry, and suddenly this practice became official. The award provided enthusiastic support, funding, protected time, and weekly supervision. I am now over the halfway point in this two-year journey and have benefited immensely from lively discussions in supervision, cross-specialty literature reviews incorporating philosophy, literature and medicine, and meaningful experiences writing with my outpatient psychiatry patients.
Patients aren’t the only ones who can benefit from building a narrative. Just as I’ve found it beneficial, so can other physicians and students who are struggling with stress from their practices, training, or other elements of their lives. In this article, I will discuss three benefits of integrating the written word into psychiatry training, three practical strategies to incorporate writing into clinical or personal practice, and three barriers to implementation with strategies to address them. These practices can also be used to help heal our healers.
The first intervention is called the Grief Poem.
The Grief Poem starts with this prompt: “Acknowledge that you have lost someone or something; write a letter/poem addressed to your lost one; tell them about your wishes, fears, angers, desires, sorrows; thank them if you wish or express other things left unsaid.”
Enter my patient, whom I will call Heath, a man in his early twenties with history of recurrent depression refractory to multiple medications. He was described as “noncompliant” with treatment due to self-discontinuation of most of the medications that were prescribed to him. His symptoms included insomnia, anxious ruminations, panic attacks, poor self-esteem, emptiness, and a profoundly disrupted sense of self. He shared that he had passive suicidal ideation with intrusive thoughts about the traumatic death of a very close friend several months prior, whom he had cared for until she passed.
Heath had dropped out of college and worked as an assistant in a busy creative firm where he was often verbally harassed and belittled by his boss; he also described early verbal and emotional abuse from his father, paired with an absent mother. He was a self-identified poet. His goals were simply to "feel better" and he admitted to a fear that medications would numb his creativity. I diagnosed him with recurrent depression through the lens of complex bereavement and disrupted attachment.
I was able to see Heath monthly for 30- to 60-minute medication management appointments. Our early work together mirrored that of my well-meaning predecessors, as I carefully selected medications for him that he would, respectfully, discontinue after a few doses. In the interim between medication trials, we discussed grief in comparison to depression and I asked him to write about his friend who had passed away.
In our next medical management appointment, he brought me a poem. I cannot publish it here, but I can share the impact it had on me. Through this poem, which conveyed a deep relationship of epic, marvelous, mythic proportions, I finally understood that this man had lost someone who had been a mother, lover, mentor, and fierce companion, as if she were the Mother, Priestess, Magician, and Fool wrapped into one. When he shared this with me, we could finally consider together what he had been forced to carry alone, and I came to understand him more profoundly through these few words than what I had been able to grasp in months of appointments.
Thus, the benefits of the Grief Poem for the patient and provider include aiding in diagnostic clarity and patient formulation and building rapport and joint meaning-making. Your own Grief Poem can help you, as a physician, recognize and honor what you have lost, whether it be an element of identity, trust in the system, or patients themselves.
Intervention #2 is called The Co-Narrative Letter. This technique is based on the practice developed by Dr. SuEllen Hamkins, detailed in her book The Art of Narrative Psychiatry. I tried to emulate her approach, employing a strengths-based interview with emphasis on co-formulation of problems and a patient-driven treatment plan, followed by communication of my assessment, plan, and formulation through a letter addressed to my patient. The framework for writing a Co-Narrative Letter includes sharing the clinical assessment, reflecting on the patient’s strengths, struggles and goals using their own words, posing questions to prompt further reflection, and then asking the patient to revise and correct the letter. In this way, the patient is coached to author their own narrative, which the provider uses to refine the assessment and guide the treatment plan.
I wrote a closure letter for Heath at the end of our year of treatment. Some of the questions I included were:
Does recovery mean losing part of yourself?
When have emotions crossed the line from fueling creativity to paralyzing your mind or body?
Who in your life do you impact by sharing your creative gifts?
How did you manage to feel pain while resisting despair?
The Co-Narrative Letter offers an explicit opportunity to mirror the patient, prompting deeper reflection outside of appointment time for the dyad, and a continued sense of agency for the patient who can author their treatment by crafting their narrative. This intervention is more time-consuming compared with others, requiring an extra 20-30 minutes outside of the appointment time.
After implementing letter writing with patients, I’ve come to wonder if this same technique could be used in supervision to enhance the trainee-attending dyad. Rather than exchange a succinct feedback summary, letter writing is a way to share a detailed assessment of perceptions across time and from multiple perspectives. This invites the creation of a dynamic portrait of growth for all who are involved, which is unique, intimate, and highly valuable.
Intervention #3 is Timed Free Writing. The prompt is: Think about a memory that has had a powerful impact on you, but that you have never fully shared with anyone. Go to a private place, set the timer for 15-30 minutes and write about the emotions that this experience evokes for you. Repeat this exercise three to five times per week for three to four weeks.
This is the most accessible, least structured of the interventions, and perhaps the most familiar. This can be loosely conceptualized as journaling, however I invite practitioners to lean into the emotional landscape when employing this exercise.
Clinical psychologist James Pennebaker, Professor Emeritus of Psychology at the University of Texas, conducted several studies investigating the effects of writing on human physiology. His data suggests improved immune function, autonomic regulation, and subjective improved emotional regulation in the participating subjects when they engaged in timed emotional writing compared with writing about mundane subjects such as schedules. I have found that of the above interventions, Timed Free Writing has served as a profound personal catalyst for processing traumatic experiences, unsettling transitions, and to help solidify my sense of self.
Journaling has long been known to have positive benefits, including relieving stress, helping to build confidence, tracking progress toward goals, and finding inspiration. Just as patients can use writing to demystify thoughts and emotions, or document how they are moving forward, physicians and students can also find strength and clarity in writing about even mundane events of their day.
Despite the clear benefits of writing, roadblocks remain. Barriers can include a perceived lack of creativity, the idea that “I am not a writer,” lack of time, or lack of inspiration. To resist succumbing to the inertia of not writing, equip yourself with prompts ahead of time, such as those suggested in this article. These exercises often take less time than expected (15-30 minutes), can be done in the patient’s or provider’s own time outside of clinical constraints, and are enriching enough to merit personal time. More radically, we could shift the priority from other interventions and documentation in order to prioritize these.
The benefits of integrating writing into psychiatry through the Grief Poem, the Co-Narrative Letter, and the Timed Free Write are myriad: they can improve diagnostic clarity and aid in crafting formulation, along with catalyzing the therapeutic rapport as an opportunity for joint holding, mirroring, and meaning-making with patients. Writing also serves as a way to cultivate an invaluable sense of personal integration — and resilience — in trainees and help established physicians fight sources of stress and burnout.
I imagine this practice will offer solace to physicians at any stage of their career. As one maneuvers between compartmentalization, often necessary for prevention of mortality, and emotional processing, which is critical to retain a sense of humanity, the course can at times be treacherous. The written word is always within reach and can be used to stay on course.
Estelle Dolan, MD is the first recipient of the Mark and Tanya Schaal Prose and Poetry in Psychotherapy Award at UC Davis.
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