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When, where, and how to use poetry in a clinical setting.
It is hard to believe that 17 years have gone by since I published a piece in Psychiatric TimesTM, titled, “The Poet and the Psychiatrist.” At that time, I alluded to “an unusual therapy group” I co-led as a resident, nearly 40 years ago, in which psychiatric inpatients “… were encouraged to bring in poetry—whether their own or that of others—and read it to the group. A psychiatric nurse and I encouraged discussion of the feelings, images, and memories the poems would almost invariably evoke.”1
We often found that patients who rarely expressed their feelings in the course of a formal therapy session would do so in the context of the poetry reading. Sadly, the very idea of conducting such a group in today’s climate of truncated psychiatric care seems quaint or naïve, at best. This point was brought home to me in a recent piece by Psychiatric Times’ Editor-in-Chief, John J. Miller, MD, in which he detailed the economic pressures on psychiatrists over the past 30 years, leading to the now infamous “15-minute medication check.”2
Dr Miller pushed back on this procrustean limit by suggesting—or at least, imagining—that psychiatrists extend the session to 16 minutes. The extra minute, he suggested, could be used to gain some important personal information about the patient. Questions might include, for example, “Who do you feel had the greatest influence on you growing up?” or “When do you feel most at peace with yourself?” or “What do you do for relaxation?”2
Riffing off Dr Miller’s suggestion, I would like to propose another question that we might put to certain suitable patients—a question I raise as both a clinician and a poet.3 But first, I would like to examine the whole notion of the medication check, with the aim of reimagining it as something more than a superficial exercise in refilling a script.
Pushing Back Against the 15-Minute Limit
For starters, I would urge psychiatrists to resist the 15-minute med check model, wherever and whenever possible. I realize that will not be greeted with enthusiasm in most managed care settings, but I think there are good reasons—and compelling ethical imperatives—why we should push back hard. As child psychiatrist David Rettew, MD, succinctly put it, “In 15 minutes…there is barely enough time to go over side effects, dose and medication changes, and informed consent, let alone engage in discussions about what may really be going on in a patient’s life and how a multitude of other possible interventions (improving sleep, exercise, nutrition, relationships) might be useful.”4
There is good reason to believe that resistance is not always futile. For example, in 2011, Lorraine Roth, MD, commented as follows:
“I retired from the VA last year and have worked a number of Locum Tenens positions since then. One was at a mental health clinic that needed a psychiatrist to cover for a few months. They stated that evaluations were one hour, med checks 15 minutes. I said I need 30 minutes. I explained that 15-minute checks are adequate for those patients who are “doing well, just need a refill,” but 30 minutes allows for the adequate evaluation and decision-making necessary for patients who are not doing well. In addition, it is essential to write a good progress note, and trying to include that in a 15-minute slot is not workable. They granted my request for 30-minute med checks.”5
The situation has probably worsened since Dr Roth posted her comments, and not all psychiatrists will have the leverage she apparently had. Still, I believe that serious pushback is worth a try.
Humanizing the Med Check
If you must see patients for only 15 minutes, try to find a way to humanize what might otherwise be a perfunctory, robotic encounter. For example, H. Steven Moffic, MD, has explored the usefulness of asking med check patients, “What gives you meaning in your life?” Or, more colloquially, “What keeps you going?” Dr Moffic asked patients to write out their answers prior to the 15-minute med check, and found that this 1 question often elicited important information. For example, one patient answered like this: “DS, who had posttraumatic stress disorder (PTSD), answered, ‘Nothing.’ After I felt a chill, I asked if she felt suicidal, and she did. We changed her medication and increased the frequency of appointments.”6
It is also important not to underestimate the need for psychodynamic understanding of the patient, even—or perhaps especially—in the brief space of a med check. Glen Gabbard, MD, has observed,
“Psychiatry has probably made far too much of a distinction between psychotherapy and pharmacotherapy in training and in practice. Psychotherapeutic skills are needed in every context in psychiatry because the same phenomena that emerge in psychotherapy-transference, resistance, countertransference, schema, automatic thoughts-appear in other contexts. All clinical work in psychotherapy depends on attending to the therapeutic relationship.”7
Dr Miller made essentially the same point in his video, Making Psychotherapy Part of Every Psychiatric Visit,8 noting that from the time you greet your patient in the waiting room to the time you escort them to the door as they leave, “…everything you do is psychotherapy” and “every microsecond is a personal interaction.” Indeed, sometimes a med check cannot move to completion until the patient’s hopes, fears, fantasies, and resistances are understood and explored.7
The 1-Minute Poetic Encounter: Reimagining the Med Check
Please join me now in a brief thought experiment. Imagine you are able to negotiate with the powers that be, such that you can extend that nefarious 15-minute med check to 25-30 minutes. Let us further imagine you have a patient—Mr A, a 70-year-old divorced, retired teacher with major depressive disorder, now in remission—whom you see twice a month for med checks. He has clearly benefitted from his antidepressant (bupropion 250 mg qd), but he finds it very difficult to share any deep feelings during your meetings with him. When you ask him “How are you feeling?” he shrugs and says, “Not depressed like before, Doc. Just kind of blah.” He sees a psychiatric social worker twice monthly for supportive therapy and she reports a similar experience with Mr A. “He’s not clinically depressed anymore,” she reports, “but he just seems very closed off and shut down, emotionally flat.” You consider the possibility that his antidepressant may be causing this feeling, but—unlike the SSRIs9—bupropion almost never causes this kind of emotional flattening. In your current session, you tell Mr A that you have often found it helpful to use poetry in your work with patients. Then you ask him one simple question: “Mr A, would you be interested in using poetry to help change that blah feeling?” He seems dubious at first but says he will give it a try.
Playing out this thought experiment: might you be able to use your expanded, 25-minute med check appointment to bring poetry into the clinical context? For example, could you ask Mr A to select a poem that is meaningful to him and then allow for 5 to 10 minutes to read and discuss the poem?
This might be an occasion, as Theodor Reik, PhD, would put it, to “listen with the third ear,” whereby one “…attends to vague impressions, intuitions, images, associations, and even melodies.”10
Indeed, in my experience, the patient’s very selection of the poem can represent a kind of projective test, whereby the patient’s fears, feelings, and fantasies become attached to the poem. A few patients may even wish to bring in poems they themselves have written, which, in my experience, is often a royal road into the patient’s psychology.
Problems and Concerns: The Ideal and the Real
Alas, not all thought experiments yield good results in real life. Unfortunately, the med check context is probably not suitable for extended encounters with poetry. Having spent over 20 years in the Massachusetts Department of Mental Health, providing medication for some of the sickest patients in the state, I know from experience that time is just too tight—even with a 25-minute med check session. In one DMH facility, the psychiatric staff had to push the administration hard to be granted this generous slice of time. Some of my near-catatonic patients would take 10 minutes just to get their coats off, and another 10 minutes before they would feel ready to speak!
As my colleague and fellow poet, Richard M. Berlin, MD, put it in a personal communication (email 2/17/21),
“Even 25 minutes is a challenge, since there’s a note to write and another patient waiting. [There are] too many issues to talk about before poetry can enter. I think the group setting is probably the best context: lots of time, many interpretations, and easier to talk about the feelings/ideas that are ‘out there’ in the poem, with the understanding that poetry will be center stage.”
Then, too, there is the risk—albeit rare—of an untoward reaction to reading certain poems. In general, it is important to avoid poems that, in the words of psychiatrist Jack Leedy, MD, “…offer no hope, or that might increase the depth of the [patient’s] depression…”11 Indeed, the reading of some types of poetry may be a distressing experience for extremely fragile patients, who may regress in the face of overwhelming or primitive emotions. I once discovered this the hard way, treating a patient with borderline personality disorder and PTSD who underwent significant regression in response to poetic material, during a therapy session.12
Accordingly, careful selection of patients—and poems—is important. In general, I would suggest the use of poetry therapy for relatively stable patients who are not prone to regression, or use of primitive defense mechanisms like projection or projective identification. You should also be prepared for some spilling over of the session, in the event the poem evokes a strong emotional reaction—another reason that the med check is not an ideal context for poetic explorations. It is, however, an appropriate venue for broaching the issue.
So, what to do for Mr A? Since he is already seeing a psychiatric social worker for supportive therapy, that might provide a suitable context for the therapeutic use of poetry—provided, of course, that the therapist is amenable to the idea, and has had substantial experience with poetry therapy (PT). More information regarding PT credentialing may be found on the website of the National Association for Poetry Therapy (NAPT), or in the Journal of Poetry Therapy (JPT), edited by Nicholas Mazza, PhD, and sponsored by NAPT.13 Another option would be for the psychiatrist to see Mr A in individual or group psychotherapy, in which poetry could be integrated.
Finally, patients are not the only ones who can benefit from poetry. As Dr Berlin has written, “Doctors need poetry to bring them closer to their patients… Poetry can help doctors become better healers because poems teach us to see the world from the emotional viewpoint of another person.”14
I believe that psychiatrists who engage with poetry in their clinical work will come to understand what William Carlos Williams, MD, meant when he wrote:
It is difficult
to get the news from poems
yet men die miserably every day
of what is found there.15
Acknowledgements: My deep appreciation to Dr Berlin, Dr Moffic, and Dr Miller, for their comments and suggestions on an earlier draft of this paper.
1. Pies RW. The poet and the psychiatrist. Psychiatric Times. 2004;XXI:62-64.
2. Miller JJ. The 16-minute med check. Psychiatric Times. 2021;38,(2). https://www.psychiatrictimes.com/view/16-minute-med-check
3. Pies RW. The Doctor’s Poems. Cyberwit; 2020.
4. Rettew D. Psychiatry’s med check: is 15 minutes enough? Psychology Today. November 10, 2015. https://www.psychologytoday.com/us/blog/abcs-child-psychiatry/201511/psychiatry-s-med-check-is-15-minutes-enough
5. Roth L. Re: Psychiatry and the 15-minute med check. Machimon. July 15, 2011. https://machimon.wordpress.com/2011/07/15/psychiatry-and-the15-minute-med-check/
6. Moffic HS. The meaning of life in a 15-minute med check. Psychiatric Times. May 19, 2011. https://www.psychiatrictimes.com/view/meaning-life-15-minute-med-check
7. Gabbard GO. Deconstructing the “med check.” Psychiatric Times. 2009;26(9). https://www.psychiatrictimes.com/view/deconstructing-med-check
8. Miller JJ. Making psychotherapy part of every psychiatric visit. Psychiatric Times. November 16, 2020.https://www.psychiatrictimes.com/view/making-psychotherapy-part-of-every-psychiatric-visit
9. Sansone RA, Sansone LA. SSRI-induced indifference. Psychiatry (Edgmont). 2010;7(10):14-18.
10. Safran J. Theodor Reik’s listening with the third ear and the role of self-analysis in contemporary psychoanalytic thinking. Psychoanal Rev. 2011;98(2):205-16. https://www.researchgate.net/publication/51095312
11. Leedy JJ. Poetry As Healer: Mending the Troubled Mind. Vanguard Press; 1985.
12. Pies R. Adverse reaction to poetry therapy: A case report. J Poetry Ther. 1993;6:143-147. https://doi.org/10.1007/BF01076339
13. National Association for Poetry Therapy. Home. Accessed February 23, 2021. https://poetrytherapy.org
14. Berlin RM. Why Doctors Need Poetry. In: Practice. Brick Road Poetry Press; 2015.
15. Williams WC. Asphodel, That Greeny Flower [excerpt]. Accessed February 23, 2021. https://poets.org/poem/asphodel-greeny-flower-excerpt
For further reading:
Coulehan J, Clary P. Healing the healer: poetry in palliative care. Palliat Med. 2005;8:382-389.
Mazza N. Poetry Therapy. Routledge; 2016.
Leedy JJ. Principles of poetry therapy. In Leedy JJ, ed. Poetry Therapy. JB Lippincott; 1969.
Lerner A. Poetry in the Therapeutic Experience. Pergamon Press; 1978.
Berlin RM. Poems. Psychiatric Times. https://www.psychiatrictimes.com/cultural-corner/poetry
Coles R. Literature and medicine. JAMA.1986;256:2125.
Deluty RH. Connecting, unburdening, and enlightening: reflections on poetry and psychotherapy. Voices. 2003;39:57-62.
Pies R. Poetry therapy in the treatment of borderline personality disorder. Journal of Poetry Therapy. 1987;1(2):88-94.