Updated NICE guideline on managing violence and aggression


The National Institute for Health and Care Excellence (NICE) has just updated its guideline on managing violence and aggression in inpatient psychiatric settings (NICE 2005). The new guideline is called: “Violence and aggression: short-term management in mental health, health and community settings” (NICE 2015).

Naturally – as I lead therapeutic writing groups in acute psychiatric units – I am always interested to find out what NICE guidelines may say about the provision of creative groups/activities in psychiatric wards, and particularly whether writing groups get a mention. So I was pleased to see that the new guideline does indeed mention the provision of writing groups for inpatients in one of the domains of “a framework to anticipate violence and aggression in inpatient psychiatric wards” (NICE 2015, p9). Specifically, the domain states: “Ensure that service users are offered appropriate psychological therapies, physical activities, leisure pursuits such as film clubs and reading or writing groups, and support for communication difficulties.”

Although disappointed to see writing referred to merely as an example of a “leisure pursuit” (rather than as a complimentary therapy), I nevertheless see this specific mention of writing groups as an incremental step forward for therapeutic writing in the UK.

The wording in the new guideline is definitely an improvement on the old, which stated: “Services should be able to accommodate service users’ needs for engaging in activities and individual choice – there should be an activity room and a dayroom with a television, as boredom can lead to disturbed/violent behaviour” (NICE 2005, p14).

Unfortunately, most NICE guidelines do not mention provision of creative activities in their recommendations. The small number of current NICE recommendations that do refer to creative therapies and activities include:

“Ensure that service users in hospital have access to a wide range of meaningful and culturally appropriate occupations and activities 7 days per week, and not restricted to 9am to 5pm. These should include creative and leisure activities” (NICE 2011, p22).

“Consider offering arts therapies to all people with psychosis or schizophrenia, particularly for the alleviation of negative symptoms. This can be started either during the acute phase or later, including in inpatient settings” (NICE 2014, p25).

Getting therapeutic writing embedded into the recommendations of UK clinical guidelines is probably not going to happen anytime soon, but with the publication of the new NICE NG10 guideline we have taken a small step forwards.


NICE (2005). The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments. London: National Institute for Health and Care Excellence, CG25, February 2005. Retrieved 30/05/2015 from: https://www.nice.org.uk/guidance/cg25/resources/guidance-violence-pdf

NICE (2011). Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services. London: National Institute for Health and Care Excellence, CG136, December 2011. Retrieved 30/05/2015 from: http://www.nice.org.uk/guidance/cg136/resources/guidance-service-user-experience-in-adult-mental-health-improving-the-experience-of-care-for-people-using-adult-nhs-mental-health-services-pdf

NICE (2014). Psychosis and schizophrenia in adults: treatment and management. London: National Institute for Health and Care Excellence, CG178, March 2014. Retrieved 30/05/2015 from: https://www.nice.org.uk/guidance/cg178/resources/guidance-psychosis-and-schizophrenia-in-adults-treatment-and-management-pdf

NICE (2015). Violence and aggression: short-term management in mental health, health and community settings. London: National Institute for Health and Care Excellence, NG10, May 2015. Retrieved 30/05/2015 from: http://www.nice.org.uk/guidance/ng10

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Finding a poem

found poem

[Image from Mr Miller’s English Language Arts Blog and found using Google Images]

Creating found poetry means taking words, phrases and lines from other sources and using them to create poems. I’d like to tell you about two kinds of found poems I have been introduced to and enjoyed.

1. Finding poems in published prose

I first heard about this type of found poetry from Kirsty Stanley, who is an occupational therapist and a writer. On her blog, Kirsty has included found poems she crafted by photocopying a page of a book or magazine and creating a poem by artistically highlighting selected words and phrases on the page. This is a fun technique that can create something quite unexpected – for example a poem on a topic that is different both from your usual poetry and from the source text.

For the poem I have included below (Stalled), I didn’t use quite the method Kirsty describes on her blog – she creates a poem directly on the photocopied page (like the example above from Ezra Miller’s blog), whereas in my poem I typed the words up and inserted line breaks where I wanted them. However, like Kirsty, I didn’t add or change any words or change their order.

The method I used was: (i) photocopy a page (two pages in this case) from a book; (ii) select and highlight words, phrases and sentences to include; (iii) type them up; (iv) insert line breaks; (v) fine tune, e.g., by adding or removing words (ensuring that any words added are taken from the text and in the original order).

I have scanned and highlighted the double-page spread from a novella, A Penny Spitfire by Brindley Hallam Dennis, published by Pewter Rose Press, that I used to create the poem ‘Stalled’ (see below). I used pages 82-83 (reproduced with permission).

BHD extract

If this type of found poem is new to you, my tip would be to choose a page with plenty of words and little or no dialogue. This is a technique to play with – just have a go and see what you find.

Stalled (‘found’ in A Penny Spitfire by Brindley Hallam Dennis)

His workshop
stood untouched,
encrusted with dirt
and cobwebs.
Spiders hunted in
threads of silk.

He’d changed.
Raw edges where his
life had torn,
had hardened.
Pain turned
to numbness.

She too changed,
The simplest things
divided them.
They began to live
as strangers.

He tried to remember
what they had before
but it seemed far away.
They had lost something,
did not mesh anymore.

They could not talk
about the past.
Yet he sensed
through words they could
come back together.

But how did you do that?
How tell the things
he wanted to tell?
Even thinking about them
made him shake inside.

2. Poems ‘found’ in conversations with others

On a Writing in Healthcare course at Ty Newydd I learned about another kind of found poem from poet, tutor and cofounder of Lapidus, Graham Hartill. Graham told our group about found poems he has created from notes he made of conversations with inmates when working as a poet in a prison. This technique can be used or adapted to give someone who doesn’t consider themselves to be very creative, or who does not or cannot write much, the experience of writing a poem.

Here I describe using the technique to create a found poem about a child’s experience of World War II. My mother was 10 when WWII began. To create a found poem based on her memories I first interviewed her about the war. During the interview I made rapid notes and also recorded the conversation. Later I typed up the main ideas from her responses, sometimes but not always using her words. I played with the order of the ideas until I felt I had them grouped and in a logical order. Then I played with the lines themselves, editing and refining to turn whole sentences into the lines of a poem that I hope has rhythm and flow. Finally I checked back with Mum to see whether she was happy with my poem ‘Make do and mend’ (see below).

Make do and mend

I was 10 when war started.
We kids didn’t hear much about the fighting. Just
what was on Pathé news at the pictures.
The man had a funny voice.

None of my family joined up.
Young men had a choice: go down the pit or go to war.
My Dad was a miner, and my brothers,
those that were old enough.
I remember seeing young men on the buses though,
off to start their training.

There was an army camp near us.
The soldiers unwound electric cable
right through the village. To untangle it.
Then they wound it up again.
Our Mary tripped over it, broke her leg.
She got fifty pounds.

Clothes were on ration.
Mostly it was make do and mend.
A lot of folk knitted. Pulled out old things
to knit new. Cut down women’s dresses
to make clothes for kids.

You had to queue to get stuff.
Me and Lil walked four miles to queue for a pork pie.
Dad grew vegetables. And mushrooms.
Mushrooms were dear then.
He dug a pond in the garden and kept ducks.
God they made a mess.

He raised cockerels for Christmas.
And in our stocking: an apple, an orange
and a few pennies.
We made cakes with powered egg.
Grated carrot in the Christmas pud
made the fruit go further.
Mam could make a meal out of anything,
a ham bone and a few peas.

You couldn’t get Christmas trees.
Me and our Jamie cut the top off a holly tree.
From up the top I could see a Lancaster
belly up in a field. Jamie wanted me to get down
so he could climb up and see. But I wouldn’t.
We crept along the hedges to get a better look,
snuck past the men in uniform,
the army and air force police.

One night the Germans dropped incendiaries.
Mam made us hide on a mattress under the stairs,
me, Jamie and Lil, while she stood at the door
watching planes trying to bomb the mines.
They missed. And me and Jamie crept
under the kitchen table while Mam wasn’t looking
and pinched some raisins.

…now go and find a poem or two – play, have fun, enjoy!

This post (most of it) first appeared on the Poetry Space blog.

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Red Rucksack

Red RucksackIt’s lasted well,
his red rucksack.
Zip often strained to bursting
but not bursting.

Thin and light when empty
bulky and heavy as he
jogs and it bobs
down our road and
across the field
to school.

And such a comfort
the brilliant red of it.
I see it as a small
scarlet blur
crossing the school yard
safely arrived
unaware of my gaze.

It has lasted well
but its days are
numbered now.
Big school beckons.
The new cool black bag
already waiting in the hall,
making the old look
childish and small.

I wrote this poem (and took the photo) when my son was about to start secondary school seven years ago. I’m posting the poem now because my son went to his secondary school Leavers’ Assembly yesterday, and when his exams are finally over on 18th June his school days will be over too. He is about to start a new chapter of his life – hopefully at university.

And it seems scarcely two minutes since I watched his red rucksack bobbing along as he jogged towards his last day at primary school.

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Therapeutic writing workshop

Hand writing

This post is based on a handout I created for a 2-hour workshop on getting started with writing for wellbeing.

Research shows that writing can benefit your health and wellbeing, but so far no-one knows how it works. No special talent, ability or imagination is needed. Many people would enjoy writing, and benefit from it, if they just had a push to get started. Whatever you write is right for you. Trust yourself to write whatever you need to write.

My advice to people about writing for wellbeing is based on my belief that many kinds of writing can be therapeutic in different ways. For example: you do not have to write about unhappy thoughts for writing to be therapeutic. People can also benefit from writing about happiness or joy, or writing about the world around them.

The types of writing I use and recommend include: mindful writing, writing a journal or diary, writing from a different perspective of some kind, and writing about positive experiences and memories.

Exercise 1: Mindful Expressive Writing

This technique involves writing to describe how you feel right now. Do not add thoughts or associations. Write non-judgementally. Write only about how you feel in this present moment. Sometimes I combine mindful expressive writing with metaphor, for example: “What kind of weather am I right now?”

bare feet

The workshop exercise (body scan write): (1) Take 5 minutes to write about how you feel physically. Starting at your toes and moving up, write about how each part of you feels – hot or cold? Comfortable or uncomfortable? Tense or relaxed? Tingly? Painful? (2) Now write for 5 more minutes about how you feel emotionally and mentally right now.

Exercise 2: Mindful Descriptive Writing

I think of this as a writing meditation: choose an object, or a photograph of a beautiful place, and write to describe it in some detail. Don’t add thoughts, associations, feelings. Just write a description of the picture or object. Or, better still, notice something in the real world, perhaps the view around you or out of the window, and write to describe it. If possible include description of more than just what you see, for example: the taste of your coffee, the sounds the birds are making, the scents of the flowers, how the garden wall feels under your fingers. Mindful descriptive writing is the therapeutic writing technique that I use more than any other. I recommend a daily journal practice of 5 minutes per day of mindful descriptive writing and 5 minutes per day of mindful expressive writing for general wellbeing benefits and stress relief.

You should practice doing other things mindfully too, like observing the bubbles when you do the washing up, or listening to the birds singing and all the other sounds around you when you wake in the morning.

The workshop exercise (mindful writing about something in the real world): (1) Write for about 6-8 minutes to describe an object in detail – how it looks, smells and feels (this is the mindful writing bit). (2) Optional second part: write for another 6-8 minutes about any thoughts, memories or associations that spring to mind. This second part of the exercise is not mindful writing – so let the writing take you where it will, and write from your imagination if you wish.


Exercise 3: Captured Moments

This is a technique developed by Kathleen Adams and described in her book Journal to the Self: Twenty Two Paths to Personal Growth (see Further Reading). The idea is to write about a moment of your life, for example: a moment of joy, sadness, delight, anguish, exhilaration or serenity, and really bring it to life by including as much detail as you can remember about what you could see, smell, hear, taste and feel at the time.

The workshop exercise: Write for 15 minutes about one of the happiest moments you can remember. Include as much detail as you can about what you could see, hear, taste, smell and feel in that moment. Alternatively you can write about any moment that you remember very strongly.

Exercise 4: Beginnings and Endings

This is a very flexible writing exercise and so it is not really possible to say what type of therapeutic writing technique is involved as that depends on what you decide to write about. For example: you might write about: an emotional ending (Expressive Writing), a memory of the start of something wonderful (Positive Writing), a new that beginning you long for but that hasn’t happened yet (writing from another Perspective), or something completely from your imagination (Creative Writing).

Workshop exercise: Write for 15 minutes about either a beginning or an ending, for example: starting school, moving to a new place, losing a loved one, retiring from work, becoming a parent, meeting someone new. Write from memory or from your imagination. Write about yourself, someone you know or a fictional character.

Exercise 5: Mindful Descriptive Writing (2)

Workshop exercise: write about everything you can see, hear, taste, smell and touch in the room (or wherever you are) right now. As described above, write without adding your own thoughts or judgements or associations.

Further Reading

More handouts and ideas for writing are available on this blog.

Words for Wellbeing, edited by Carol Ross, published by the Cumbria Partnership NHS Foundation Trust. Available on Amazon, or direct by post for £9.50 from: Carol Ross, Carleton Clinic, Cumwhinton Drive, Carlisle, CA1 3SX (make cheques payable to Cumbria Partnership NHS Foundation Trust).

Journal to the Self: Twenty Two Paths to Personal Growth, by Kathleen Adams, published by Grand Central Publishing.

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Money from self-publishing – it’s not just about how many books you sell

A great post about self publishing.

Jenny Alexander's blog: Writing in the House of Dreams

Just after I self-published Writing in the House of Dreams I blogged about my financial outlay in Self-publishing: What are the actual costs? Five months on, I thought you might like a progress report.

I initially registered the book in the amazon Select programme, which meant I couldn’t publish through any competing outlets for at least 90 days. The benefit of Select is that you can offer your book either free or on a sliding scale of reduced rates in a promotion which, while not making you any money, should make your book more visible and improve its amazon sales ranking.

I didn’t realise that you could only do one promotion in the 90 day period, and I don’t think the one I did really achieved anything for my book, so I wouldn’t personally enrol a book in the Select programme again.

As soon as the 90 day period was up, I…

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Fourteen ways to boost your creativity

There are some great ideas here for boosting your creative thinking … http://m.dailygood.org/story/1011/14-surprising-ways-to-boost-creativity-ed-decker/

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Words for Wellbeing link on Amazon

Just a reminder that you can get Words for Wellbeing on Amazon:

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My 200th post – a celebration of Words for Wellbeing

Carol Ross

This is my 200th post on this blog so I thought I’d make it a celebration of the Words for Wellbeing book. Just to remind you … Words for Wellbeing is a not-for-profit book, published in July 2012, that aims to encourage people to write – and read – to help their health and wellbeing, and to act a resource for practitioners.

I’ve heard that for a self-published book to sell over 100 copies is pretty good. Words for Wellbeing has sold over 300 so far, including 70+ on Amazon, and sales continue to trickle in. As agreed in the original funding application, the book was also distributed free to Cumbrian libraries (NHS, academic, secondary school and County Council) and to clinical teams within the Cumbria Partnership NHS Foundation Trust (the publisher of Words for Wellbeing).

We were exceedingly fortunate to have the acclaimed author Jim Eldridge write the Foreword for Words for Wellbeing – which I feel sure has helped the success of the book. Extract from his Foreword: “The healing process should be holistic, and where complications – often emotional – prevent that healing, then writing is a hugely powerful medical tool.”

Nursing Standard Review

The book has attracted some glowing reviews – some of which I may not even have seen yet given that I only recently stumbled upon a review of Words for Wellbeing in a Nursing Standard from last July! Here are some extracts from Words for Wellbeing reviews:

Nursing Standard 28(48), July 2014: “There are many inspiring examples from seasoned authors and those new to writing, and good guidelines for group work” written by retired community mental health nurse Peter Barraclough who gave the book 4 stars (out of 5).

British Journal of Occupational Therapy 76(5), May 2013: “as a consultative tool, on hand to inspire and provide reality checks for anyone else working in the field, Words for Wellbeing blends wisdom with a warm pragmatism; it achieves the impressive feat of combining authority with a genuine sense that the editor, Carol Ross, is in the room, using her personable prose style to address herself directly to the concerns of the individual reader ” written by Jane Nixon (psychotherapist and trainer working in private practice) and Neil Nixon (lecturer in professional writing, author and journalist).

Mental Health Practice 16(8), May 2013: “This book would be beneficial for those interested in helping people use words creatively as a tool towards recovery and growth, and in aiding personally reflective practice” written by Charley Baker, a lecturer in mental health at the University of Nottingham.

Extracts from the Macmillan website reviews, which were written by people affected by cancer: “This is an excellent book that would be useful for anyone suffering from depression or recuperating from any major operation”; “As someone who has already discovered how words and writing can change my life, I found it such a joy to read this book and share other people’s experiences. It will be particularly useful for dealing with the emotional effects of cancer.”

ShamanismBooks blog: “as well as benefiting health professionals who want to set up writing groups and individuals who have experienced health problems, this book would be very suitable for anyone who is interested in writing for pleasure” written by June Kent, Editor of Indie Shaman Magazine.

Thank you everyone Jim Eldridge and everyone else who contributed to the book or otherwise helped with it, including: Victoria Janet Field, Marilyn Messenger, Katie Metcalfe, Suzanne Kelsey, Lisa Rossetti, Geraldine Green, Gillie Bolton, Dave Miller, Jessica Lucas, Vee Howard-Jones, Elizabeth Gates, Eileen O’Reilly, Sylvia Stevens, John Berry, and many others (click here to view the contents pages).

Click here to go to a page where you can download some sample chapters.

Words for Wellbeing has been in print for three years this summer. Over 300 have sold and I have around 300 left. Here’s hoping that for my 300th blog post I will be reporting that it is out of print – sold out!

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This has been an inspiring week for me in respect of my therapeutic writing groups. Which has got me thinking about the relationship between the therapeutic benefit of my groups (for patients), and inspiration (theirs and mine). Does it happen that when I feel personally inspired about writing, I become more effective both at providing inspiration to others, and at managing groups? Or, alternatively, do I become more inspired about writing during sessions where I feel that the patients present are really engaging with the writing exercises and therefore (I believe) benefiting from attending the session? Or is what happens more like a mixture of the two, i.e., I start out a bit more inspired than usual and so better able to inspire the patients, who then engage better with the writing exercises, which I notice, and which feeds my inspiration, and so on. Whichever of these possibilities is true, it is clear to me that something different happens when therapeutic writing is facilitated in a group rather than being done as a solitary self-help exercise. On a good day, the whole becomes much more than the sum of its parts.

After having three weeks off over Christmas and New Year for annual leave and sickness, it has taken several weeks to re-build patient interest in my psychiatric ward writing groups (at Carleton Clinic, Carlisle, UK). This lag tends to happen after each time I take a long break – even though new patients are being admitted to the wards every week. I think the explanation for the lag is that the ward staff take two or three weeks to get used to my groups running regularly again, at which point they start actively encouraging patients to participate. During this lag period I tend to feel less inspired about doing the groups, until I gradually get back into the swing of doing them, and the interest from patients picks up.

The groups

Two of my regular writing groups happened this week: a one-hour session in an adult mental health unit (Hadrian) and a half-hour session in psychiatric intensive care (Rowanwood). The term ‘group’ is somewhat misleading here, because in Rowanwood sessions are very often one-to-one. This is partly because there are fewer patients in Rowanwood than in Hadrian, and they are more unwell, resulting in fewer patients attending the sessions; and partly because patients who are more unwell generally prefer not to participate in company with other patients. Having said that, this week’s session in Rowanwood was a group of two patients participating simultaneously (although not really together). In Hadrian, I generally work with a group of between two and seven patients, but the patients in the group change from week to week. This week four patients participated in the Hadrian session.

In both sessions I used a door-themed poem and photograph as writing inspiration. In Hadrian, as the session was longer, I also used a photograph of a complex wooden box as inspiration for a second writing exercise. The poem was ‘The Door’ by Miroslav Holub. We read the poem aloud and briefly discussed it. Then I showed them a colour photograph of a wooden door, which looks like the door of a cottage. I suggested they might use either the poem or the photograph as writing inspiration, for example, they might write about what they would want to find on the other side of the door depicted in the photograph. As always, I stressed that spelling, grammar, punctuation and handwriting do not matter and that participants do not have to follow my writing suggestions – that they are always free to write whatever they wish. For the second exercise inspired by the photograph of the wooden box I suggested they might write about what is inside the box, what they might keep in the box, or perhaps imagine that the box is magic in some way.

I hope you will see from this post that, if the writing practitioner takes a flexible approach, one writing exercise can work very differently for different individuals.

The patients and their writing

Angela is a middle-aged woman who has been in Rowanwood psychiatric intensive care for some time. Whenever I have encountered her she has seemed confused and restless. She wrote with me a few weeks ago, but then she stayed at the table for only ten minutes and wrote about four or five lines. This week she stayed half an hour and wrote almost a page of A4. She said she was inspired by the lovely golden colour of the door in the photograph I’d brought. Angela’s writing on this occasion, although not entirely grammatically correct, was nevertheless understandable. She wrote partly descriptively about what she could see in the photograph – the door, the steps, and the plants in pots on the steps; and partly interpretatively, for example, she wrote that the slate steps suggest strength, that the plants suggest a welcome for invited guests, and that the closed door suggests that uninvited people will not be made welcome.

Although Bob (Rowanwood) seemed quite distracted by his own thoughts, he stayed at the writing table for about twenty minutes. He is about thirty. He said that he liked the poem very much, and he spontaneously read it aloud after I’d read it. He wrote very little, and nothing at all about the photograph or the poem. He wrote only that that he would like to be given the opportunity for a new start in life. I suggested that Bob could tell the doctor that when he met him later.

In Hadrian, the door theme started forty-year-old Colin talking about how he would not want to let strangers in through his door. What he wrote was about his relationship with his family and about the family house that he used to live in by himself. He read his writing to the group, and then elaborated on his written words by telling us about the police coming to his house and taking him off to hospital, about his relationships with family members, about his wife being abusive to him, cheating on him and then leaving him, and about the house he used to live in. It seemed as though the ten minutes of writing he did had helped Colin to express his feelings. Colin does not understand why he is in hospital and he wants to leave. We were supportive to Colin but we did not encourage him to continue talking about his feelings. Instead, we suggested that Colin request a one-to-one talk with his named nurse, tell him/her how he feels and ask any questions he wants to ask. Colin left before the session ended.

Twenty-year-old Diane (Hadrian) arrived as we were finishing the doors exercise. She was restless and talkative and (I guessed) probably going through a manic episode. She came in and out of the activities room several times during the session. Nevertheless she managed to write at least a page and read her writing aloud to the group. She wrote imaginatively about a magic box. When she read her writing aloud I found it difficult to follow the meaning. I asked her to read it again. The second time she read more slowly, and corrected some mistakes, so the meaning was easier to follow – although still not entirely clear. She said that she enjoyed doing the writing and interpreting her own writing.

Elspeth (Hadrian), another young woman of about twenty, appeared to be on the verge of tears in the early part of the session. Her writing was fairly emotional, for example, she wrote about a door that might have good things beyond but that she was too afraid to open. However, she said that she had enjoyed the session, especially listening to the rest of us read our writing aloud. She no longer looked tearful by the end of the session.

Fay (Hadrian) is a middle-aged woman who enjoys arts and crafts as well as writing. She produced two pieces of creative, enjoyable and quite poetic prose in response to the two writing exercises. In the door-themed exercise she wrote about a door holding back a bursting flow of burning lava. She said it was a metaphorical account of what had happened the previous day. Her piece about the wooden box was very imaginative – she wrote about the box having magic powers that enabled her to fly. Fay said she enjoyed the session, and she found it helpful to be able to stop thinking about her problems and allow her mind to be creative for a time.

And as for me, inspired by the photograph of the door I wrote the start of a short story about a woman who rents a cottage having never seen it, receives the front door key by post, and moves in to start a new life there. During the wooden box exercise I wrote some more toward the same story, the box being a wrapped gift left by the previous occupier for the incoming tenant.

I love it when a week like this one happens and I feel inspired all over again both for my own writing and for my therapeutic writing practice. I’m still unsure where the inspiration started – whether with me as an individual or in the group process – but whatever its source, I’m glad it’s here.

Note: participants’ names have been changed to protect their identities.

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Nursing Standard review of Words for Wellbeing

I only just noticed today that the Words for Wellbeing book was reviewed last August in the Nursing Standard! Volume 28, issue 48, page 30.

It’s a really positive review written by a retired mental health nurse and he gave the book four stars 🙂

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