Poetry therapy

1. Introduction

Version followed: Nicholas Mazza's RES (Receptive/prescriptive, Expressive/creative, Symbolic/ceremonial) practice model, as given in Poetry Therapy: Theory and Practice (3rd ed., Routledge, 2022) and described in Mazza & Hayton's model study, Mazza's own workshop outline, and secondary accounts of his group procedure, including a published study of two recorded RES-based sessions (Holttum et al. 2022). The professional frame is that of the National Association for Poetry Therapy (NAPT) and the International Federation for Biblio/Poetry Therapy (IFBPT). [source: Routledge; Mazza & Hayton; Mazza FSU outline; Ramsey-Wade & Devine]

The RES dimensions and the techniques Mazza names draw on Mazza & Hayton, Mazza's FSU workshop outline and Holttum et al. (2022). Hynes & Hynes-Berry's four-stage process, Leedy's isoprinciple and the CAPF credential rest on sources that cite the originals (Kosonen 2019; Shah & Sanu 2023; Franks 1974; O*NET) [uncertain on detail]. The text of Mazza's book is not drawn on, so session details beyond the sources named are tagged. No published procedure of Mazza's for the cluster poem or the dyadic poem is documented, so the steps given for them are [synthesis].

Poetry therapy is the intentional use of written or spoken words (published poems, song lyrics and other texts, plus the client's own writing) by a trained practitioner to support therapeutic goals [source: HPN, Poetry Therapist]. NAPT calls it a specific form of bibliotherapy, set apart by its use of metaphor, imagery and rhythm [source: NAPT History]. It is a method used inside other therapies, not a school of its own: it can sit within CBT, psychodynamic, family or person-centred work and is described as an adjunct, not a replacement [source: Ramsey-Wade & Devine; NASW News].

How change happens (as the sources describe it):

A fitting poem can put words to a feeling and so validate it. It also opens the way to talking about oneself and gets group discussion moving. [source: Mazza & Hayton]
Writing works as a "safety valve" for feelings and gives order and control over hard experience [source: Mazza & Hayton; NASW News].
Metaphor, ritual and story help people mark life transitions and loss [source: Mazza & Hayton].
Working through the poem, rather than straight at the problem, is indirect. This may suit clients who are highly defended. [source: Ramsey-Wade & Devine]

History (verified):

Eli Greifer, a poet, pharmacist and lawyer, ran poem-therapy work in New York from 1928. He led groups at Creedmoor State Hospital in the 1950s and at Cumberland Hospital in 1959, and he influenced psychiatrist Jack Leedy. [source: NAPT History] (The NAPT page spells it "Creedmore".)
In 1969 Leedy founded the Association for Poetry Therapy (APT) with Ann White and Gil Schloss [source: NAPT History].
Arthur Lerner, PhD, became poet-in-residence and poetry therapist at Calabasas Neuropsychiatric Center, California, in 1971. Later in the 1970s he founded the Poetry Therapy Institute. [source: NAPT History]
Arleen Hynes, a librarian at St Elizabeths Hospital, Washington DC, set up the first full training programme in 1974. APT became NAPT in 1980, and the credentialing federation was formed that same year. [source: NAPT History; NAPT Credentials]
Mazza founded the Journal of Poetry Therapy in 1987 and still edits it [source: Mazza FSU outline].

2. Framework

RES is a model of three dimensions, not a sequence of treatment phases. All three can appear within one session, and also across a whole course of therapy. [source: Mazza & Hayton; Alfrey et al.]

Dimension	What it uses	Goals
Receptive/prescriptive (R)	Existing poems, song lyrics, stories and other literature brought into the session	Validate a feeling, invite self-disclosure, start discussion
Expressive/creative (E)	The client's own writing: poems, stems, cluster, collaborative and dyadic poems, letters, journals, narrative	Release feeling safely, give order and control, build group cohesion
Symbolic/ceremonial (S)	Metaphor, ritual, symbol, storytelling, performance	Mark transitions, losses and endings, and make change concrete

[source: Mazza FSU outline; Mazza & Hayton; Ramsey-Wade & Devine]

Typical session arc. In a session the order is usually: stimulus poem (R), then a writing task (E), then sharing and discussion of the metaphors that come up (S) [source: Alfrey et al.].

A published case study describes RES as traditionally delivered in a 90-minute group, though also used with individuals, couples, families and communities. Its two recorded group sessions ran: welcome with a review of ground rules and confidentiality; a warm-up word task and a timed writing prompt; re-reading one's own writing and sharing in the group; a stimulus poem read aloud; discussion, then writing that starts from a line or phrase of the poem; and a closing reflection or intention for the week. [source: Holttum et al. 2022]

Mazza's group procedure (2003 edition, as reported in Ramsey-Wade & Devine) runs:

A brief opening round.
The group poem from last session is handed out, read silently, then read aloud by a volunteer.
Members give their reactions, which the facilitator links to their difficulties.
Further poems or lyrics are brought in and explored the same way.
The session closes with a collaborative group poem built on a metaphor that came up.
Between sessions the facilitator types up that poem and chooses poems for the next meeting.

Format and length:

Work can be individual, couple, family, group or community, in person or online [source: Routledge TOC; GoodTherapy].
Courses in the studies run from 4 days to 2.5 years, for example 7 weekly sessions, 5 × 2 hours or 6 × 1 hour. Very short courses gave weaker results. [source: Alfrey et al.]
A common practice range is 6–12 sessions [source: GoodTherapy].
One online workshop model capped groups at 12 so everyone had room to speak [source: Lets Reimagine workshop].
The 3rd edition arranges the work by modality (individual, family, group, community) and by life stage (children and early adolescents, adolescents and young adults, adults, older adults, death and loss) [source: Routledge TOC].

Criteria for moving between dimensions or levels of depth. No source used here gives formal criteria [uncertain]. Furman et al. describe early sessions that use concrete, neutral poems. Later work moves to more metaphorical, emotionally loaded material as members grow comfortable. [source: Furman et al. 2002] Further practical rules [synthesis]:

Start with R when the client is guarded, new, or has little to say. A published text lets them speak through someone else's words.
Move to E when the client is responding to texts with personal material and can stay regulated while doing so.
Use S at endings of sessions, at transitions, at anniversaries, and when insight needs to be made concrete.
Go back to R (a containing, hopeful text) after a painful E task.

Professional frame:

NAPT is a membership association. IFBPT is the separate, independent credentialing body, and the RES model underpins its training and certification standards. [source: NAPT Credentials; Holttum et al. 2022]
Training is guided independent study under one chosen mentor-supervisor and takes at least two years. It combines facilitation hours with individuals and groups, didactic study, peer experience of writing for oneself, and supervision. [source: HPN; Lapidus/Field]
Field (writing for Lapidus) reports at least 60 supervision hours and running groups in two or more settings [source: Lapidus/Field].
Credential levels (partly verified; check current requirements with IFBPT):
- Current names. NAPT says training is done by mentors who are Certified and Registered Poetry Therapists and CAPFs, and it points to ifbpt.org for the list of mentors [source: NAPT Academic Programs]. The current set is therefore CAPF, Certified Poetry Therapist (CPT) and a registered level (Registered Poetry Therapist). Mazza is listed elsewhere with the letters PTR. [source: NAPT Academic Programs; GoodTherapy; the abbreviation PTR is uncertain]
- CAPF (Certified Applied Poetry Facilitator): a background in literature and writing plus basic psychology and group dynamics. The CAPF is trained to work with healthy populations and must recognise when a distressed person needs referral to a mental-health professional. ONET lists more than two years of post-secondary education or training, more than two years of work experience, and an oral or written exam. [source: ONET CAPF]
- CPT and the registered level: GoodTherapy gives CAPF as a bachelor's degree plus 440 training hours. It gives CPT as a mental-health master's degree, licensure and 440 hours, covering independent clinical work. [source: GoodTherapy; secondary and not confirmed on ifbpt.org, uncertain]
- Older scheme: CPT for developmental settings and RPT (mental-health master's) for clinical settings [source: HPN; O*NET CPT]. Treat this as superseded wording [uncertain].
- Confirm current hours, supervision and exam rules with IFBPT (ifbpt.org) before enrolling. [uncertain]
Only people who have the credential, or are eligible for it, should call themselves poetry therapists [source: HPN].
Poetry therapy is not a regulated profession [synthesis, from the credential structure above]. In the UK, Field noted there was no practitioner-based training, and Lapidus is the relevant literary-arts-for-wellbeing body [source: Lapidus/Field].
A licensed psychotherapist may use poetry and writing techniques within their own licensed scope. They should not advertise "poetry therapy" without IFBPT training. Mazza warns practitioners to stay within their scope. [source: Alfrey et al. citing Mazza 2017; HPN]

3. Guiding principles

Anything that heals can harm. Mazza warns that "Anything that has the power to heal also has the power to harm" [source: NASW News]. Meaning: screen texts and prompts for risk as you would any intervention.
Professional purpose, not sharing a favourite. Mazza: "Just sharing your favorite poem is not professional" [source: NASW News]. Meaning: every text needs a clinical reason linked to this client's goals.
Timing and selection come first. Mazza & Hayton say timing and selection of poetic material "must always be considered" [source: Mazza & Hayton]. Meaning: choose texts for this client at this point in therapy, not by theme alone.
Match the mood first (the isoprinciple), then offer hope. Leedy (1969) took the isoprinciple from music therapy: choose poems "close in feeling to the mood of the patient" so the patient can identify with them [source: Franks 1974 citing Leedy 1969, pp. 67–68]. A depressed patient may not identify with a wholly optimistic poem, and Franks suggests one that ends on a hopeful note [source: Franks 1974 citing Litterine 1974]. Several further criteria apply:
- universal emotion, plain language and some sense of hope [source: EBSCO];
- material that reflects the client's own experience [source: NASW News, Hynes];
- texts matched to the client's interests and reading skills [source: Shah & Sanu 2023];
- accessibility, cultural relevance and readiness [source: GoodTherapy].
Meaning: meet the client's current mood first and keep a way to hope open. Skip obscure or despairing poems early in therapy.
Avoid unintended trauma triggers. For example, do not hand a poem about rape to a sexual-assault survivor [source: NASW News, Mazza]. Meaning: check each text against the client's trauma history before using it.
There is no correct reading. Clients may respond to a poem in any way that fits them [source: NASW News, Mazza]. Meaning: ask about their response; never teach the meaning or correct a reading.
No guaranteed fit. Don't assume a poem will work for everyone, but don't give up on it either [source: NASW News, Mazza]. Meaning: when a text falls flat, explore that rather than dropping it at once.
Process over product. [synthesis] Meaning: never grade, correct or edit a client's writing unless they ask. Spelling and form do not matter.
Cultural respect in ceremony. Respect culture when using ritual [source: NASW News, Mazza]. Meaning: ask what fits the client's beliefs before suggesting burning, burial or other rites. Follow the client's own traditions and do not invent sacred ritual.
Adjunct, not replacement. It is best used alongside other therapy [source: NASW News; Ramsey-Wade & Devine]. Meaning: keep the overall formulation and risk plan in charge.
Hold the client in mind. Typing up group poems and choosing the next texts shows members they are held between sessions [source: Ramsey-Wade & Devine]. Meaning: prepare material between sessions that responds to what the client said.
A safe frame. The facilitator sets ground rules, arranges the room and states session times, purpose and way of working. This reduced participants' nervousness. [source: Alfrey et al.] Following Lerner (1981), Furman et al. seat group members with no table between them, with desks or a table available for writing [source: Furman et al. 2002]. Meaning: agree the rules on confidentiality, the right to pass and reading aloud before the first prompt. Arrange the room so people face each other and can still write.
Who heals the healers? [source: NASW News, Mazza] Meaning: use supervision and your own reflective writing. Boone & Castillo suggest teaching writing as self-care to workers at risk of secondary trauma. [source: Alfrey et al.]

4. Intervention inventory

The sources name these techniques, but none of the pages gives scripts. The steps below put the source descriptions into practical sequence. Where a step goes beyond what a source says, it is marked [synthesis]. Poems are named and described only, never reproduced. Use texts you or the client have lawfully obtained, and never copy whole published poems into handouts beyond what copyright allows [synthesis].

Materials and physical safety (all techniques) [synthesis]:

Plain paper, pens and printed or read-aloud texts.
Large print or audio versions for people with visual impairment or dyslexia.
The option to speak and have the therapist scribe, for people with low literacy, injury or a different first language.
For any burning ritual: use a fireproof bowl outdoors or follow the setting's fire policy, keep water nearby, and offer tearing, water-soluble paper or burial instead. Never burn anything on hospital wards or in other no-flame settings.

A. Receptive/prescriptive (R)

4.1 Stimulus poem (introducing an existing poem)

Purpose / when: To validate a feeling, invite disclosure or open a group topic. It is the default way into a session and the lowest-demand entry for new or guarded clients. [source: Mazza & Hayton; Mazza FSU outline]
Steps:
1. Choose a short text that matches the client's current mood (the isoprinciple, Section 3). It should be in plain language, hold some hope and be free of the client's specific trauma triggers. [source: Franks citing Leedy; EBSCO; NASW News; GoodTherapy]
2. Give it a brief frame without interpreting it.
3. Read it, or have it read (see 4.2).
4. Ask open questions about the client's response.
5. Link the response to the client's goals.
6. Move to writing (E) or close with discussion. [synthesis for steps 2–6, following the R→E→S order in Alfrey et al.]
Example language (illustrative): "I've brought a short poem. There's no right way to take it. Just notice what stays with you." "Which line, if any, feels closest to where you are this week?"
Watch for:
- Stimulus poems can trigger immediate emotional reactions and re-living of memories [source: Alfrey et al.].
- Signs it is working: the client moves from talking about the poem to talking about themselves, or quotes a line back later [synthesis].
Poems named in the sources (described, not quoted):
- Chavis used Natasha Lynne Vodges' "Snowbound" with guided questions about its imagery [source: NASW News].
- Peter Gross's poem series The Wasting Game, about a parent watching a daughter's anorexia, was read in an eating-disorder group. The client valued that it neither explained nor challenged the illness. [source: Ramsey-Wade & Devine]
- Max Ehrmann's "Desiderata", a prose poem of gentle life advice, was mentioned as a text one client carried in his wallet. This shows a client's own use of a text, not a protocol. [source: NASW News]
- Mary Oliver and Robert Frost are named as poets often used, with no titles given [source: GoodTherapy].

4.2 Silent reading, then reading aloud

Purpose / when: To let a text be taken in two ways, privately and then heard. Used with every handed-out text in Mazza's group format. [source: Ramsey-Wade & Devine, reporting Mazza 2003]
Steps:
1. Hand out the text.
2. Give everyone time to read it silently.
3. Ask for a volunteer to read it aloud. Never require anyone to read. [the volunteer step is from the source; "never require" is synthesis]
4. Pause briefly before discussion.
Example language (illustrative): "Read it to yourself first. Then would someone be willing to read it aloud? It's fine to pass."
Watch for:
- Shame about reading aloud, or about literacy [synthesis].
- Most of the reviewed studies involved reading poetry aloud [source: Alfrey et al.].

4.3 Reaction round and linking

Purpose / when: To turn responses into therapeutic material. Used straight after a text. [source: Ramsey-Wade & Devine]
Steps:
1. Ask what caught attention, what feelings came up, and what members disliked or would change in the poem.
2. The facilitator links these responses to members' difficulties and to change and recovery. [source: Ramsey-Wade & Devine]
Example language (illustrative): "What would you change in it, if it were yours?" "You said the last line felt too neat. Is that how advice about recovery sometimes feels?"
Watch for:
- Intellectualising or debates about craft: bring the talk back to personal response [synthesis].
- Inviting dislike is useful because it gives permission to disagree [synthesis].

4.3a Four-stage discussion of a text (Hynes & Hynes-Berry)

Purpose / when: This structures the discussion after any R text, so that a first reaction can become insight. Hynes & Hynes-Berry's interactive biblio/poetry therapy process has four stages: recognition, examination, juxtaposition and application to self [source: Kosonen 2019 citing Hynes & Hynes-Berry, 3rd ed. 2012, pp. 31–48; Shah & Sanu 2023]. The facilitator starts the process together with the client or group [source: Kosonen 2019]. The stage descriptions below come from secondary summaries [uncertain on detail].
Steps:
1. Recognition: let something in the text engage the client, in thought or in feeling. Notice what they respond to. [source: Shah & Sanu]
2. Examination: invite the client to think deliberately about that first response: what struck them, and why. [source: Shah & Sanu]
3. Juxtaposition: help the client compare their first reaction with what they found on reflection. In a group, they also compare it with other members' responses. [source: Shah & Sanu]
4. Application to self: help the client carry the new understanding into their own life. [source: Kosonen; Shah & Sanu]
5. Choose the next text to match the client's interests and reading skills, as you have assessed them. [source: Shah & Sanu]
Example language (illustrative): "What caught you first?" (recognition). "What is it about that line?" (examination). "Has your sense of it shifted since you first read it? Others heard it differently. How does that sit with you?" (juxtaposition). "Where might that show up for you this week?" (application)
Watch for: Jumping to application before the client has examined their reaction, which makes the insight feel imposed [synthesis]. Signs it is working: the client revises their first reading in their own words and links it to a concrete situation [synthesis].

4.4 Guided image questions

Purpose / when: To slow the response down and anchor it in concrete images. Useful when clients answer only "I liked it" [synthesis on when].
Steps:
1. Ask a short series of questions about particular images in the poem: what the client sees, where they would stand inside the scene, what the image reminds them of.
2. Move from the poem's image to the client's life. [source: NASW News, Chavis, described only in outline; the question sequence is synthesis]
Example language (illustrative): "If you were inside this scene, where would you be?" "Where in your own life is it like this?"
Watch for: Images can also bring back trauma memories. Ground the client if their imagery becomes vivid and distressing (see 4.27). [synthesis]

4.5 Song lyrics, film and other texts

Purpose / when: The R dimension includes songs, stories and other literature [source: Mazza FSU outline]. Field notes film and song are used as stimuli [source: Lapidus/Field]. Use with adolescents, people who dislike poetry, or when culturally closer material is needed [synthesis].
Steps: Use the same sequence as 4.1. Use a short excerpt or the lyric sheet and listen at a moderate volume. [synthesis]
Example language (illustrative): "Is there a song that says what this week's been like? Bring it next time."
Watch for: Lyrics that glamorise self-harm or substance use. Explore them rather than ban them, and check current risk. [synthesis]

4.6 Client-brought material

Purpose / when: Shares ownership and shows what the client values. In Mazza's group format, any member or the facilitator may bring poems, writing or lyrics. [source: Ramsey-Wade & Devine]
Steps:
1. Invite clients to bring material.
2. Ask why they chose this text now.
3. Explore it as in 4.3. [synthesis]
Example language (illustrative): "What made you pick this one for today?"
Watch for: In groups, preview client-brought texts for content that could trigger others where possible [synthesis].

4.7 Sensory object as stimulus

Purpose / when: Hynes used objects such as an autumn leaf to stimulate the senses in reading groups [source: NASW News]. Useful with older adults, people with cognitive impairment, and children [synthesis].
Steps:
1. Pass round a safe natural or everyday object.
2. Invite sensory words.
3. Gather the words into a list poem or a link to a text. [synthesis after step 1]
Example language (illustrative): "Hold this for a moment. One word for how it feels, one for what it reminds you of."
Watch for: Allergies and food items (food hygiene). Some objects may carry loss associations, such as dried flowers. [synthesis]

B. Expressive/creative (E)

4.8 Poetic stems (sentence stems, fill in the blanks)

Purpose / when: A structured, low-threat way into personal writing. Mazza lists poetic stems and prompts as core E techniques, and the review describes "fill in the blanks" tasks [source: Mazza FSU outline; Alfrey et al.]. A related form is the blank-phrase poem (Houlding & Holland 1988, as described by Furman et al.). Clients fill in the gaps in a partly blanked poem, which eases anxiety about the blank page. [source: Furman et al. 2002] Use stems after a stimulus poem, or as the first writing for anxious clients. Adapt only texts you may lawfully use. [synthesis]
Steps:
1. Give one to three open stems tied to the session theme.
2. Set a short time, such as 5–10 minutes.
3. Say that lists, fragments and single words all count.
4. Invite sharing, with the right to pass. [synthesis]
Example stems (illustrative): "Today I am…", "What I carry is…", "If my worry had a colour…", "One thing I'd like to keep…".
Watch for:
- Stems that push straight at trauma, such as "The worst thing was…". Avoid them early (see 4.26). [synthesis]
- Signs it is working: the writing moves from general to specific, and the client adds lines unprompted. [synthesis]

4.9 Cluster poem

Purpose / when: Mazza names the cluster poem among E techniques, but his workshop outline gives no steps, and Mazza & Hayton does not mention it [source: Mazza FSU outline; Mazza & Hayton]. Use it to generate associations before writing, for clients who freeze at a blank page [synthesis]. No published procedure of Mazza's own for it was found. The steps below are a generic word-clustering method, not his. [uncertain]
Steps [synthesis]:
1. Write a key word from the session in a circle in the centre of the page.
2. Jot associations radiating out from it for 2–3 minutes.
3. Circle the strongest few.
4. Shape them into a few lines.
Example language (illustrative): "Put 'home' in the middle and let words branch off. Don't censor, then pick the three with the most charge."
Watch for: Associations that suddenly reach traumatic material. Let the client choose which words to develop. [synthesis]

4.10 Collaborative group poem

Purpose / when: Builds cohesion and gives a shared summary of the session. It is Mazza's standard group closing, and Golden studied it as a way to build group cohesion. [source: Ramsey-Wade & Devine; Alfrey et al. citing Golden 2000] Seiden describes collaborative poems in child psychotherapy [source: Alfrey et al.]. Furman et al. describe a collective poem that is passed round so each member adds a line. They cite Mazza (1985) for collaborative poems building cohesion. [source: Furman et al. 2002]
Steps:
1. Near the end of the session, name an image or metaphor that came up in discussion.
2. Each member offers a line, either aloud or on a shared sheet.
3. The facilitator writes the lines down and reads the whole poem back.
4. Between sessions, type it up and bring it to the next session as the opening text (see 4.25). [source: Ramsey-Wade & Devine; collection method synthesis]
Example language (illustrative): "We kept coming back to 'a door left open.' Let's each give one line starting from that."
Watch for:
- Members who stay silent: offer "one word is enough" [synthesis].
- Lines that reveal more than the person intended: check before typing up and circulating (see 4.28) [synthesis].

4.11 Family collaborative poem

Purpose / when: Mazza lists a collaborative family poem, and the 3rd edition has a chapter on working with families. Use it to bring out each member's view and shared images. [source: Mazza FSU outline; Routledge TOC]
Steps [synthesis]:
1. Agree a theme, such as "Our family is…".
2. Each member writes or says a line in turn, including children at their level.
3. The therapist reads the poem back.
4. Explore what was surprising and whose line is missing.
Example language (illustrative): "Each of you adds one line about a typical Sunday in your house."
Watch for:
- Power imbalances, such as a parent censoring a child.
- With coercive control or abuse, do not do joint work. Use safeguarding procedures (Section 5). [synthesis]

4.12 Dyadic poem

Purpose / when: Mazza lists the dyadic poem among E techniques but gives no steps [source: Mazza FSU outline]. Furman et al. describe a close relative used in groups. Members who chose the same feeling are put in pairs or threes, read a related poem and write a poem together, for example with every line opening on the same feeling word. [source: Furman et al. 2002] Use it with couples, a parent and child, a pair within a group, or client and therapist in individual work [synthesis]. Mazza's own dyadic procedure was not found [uncertain].
Steps [synthesis]:
1. The two people alternate lines on one theme, or each completes paired stems ("I see…" / "You see…").
2. Read the poem aloud together.
3. Discuss where the voices meet and where they differ.
Example language (illustrative): "You'll take turns, one line each, about what helps when things are tense."
Watch for: One partner dominating, or using lines to attack. Set a rule that each person writes only about their own experience. [synthesis]

4.13 Free writing

Purpose / when: Unstructured writing to release material. It is listed among current practice techniques. [source: GoodTherapy] Best with clients who are already writing comfortably and are well regulated. [synthesis]
Steps [synthesis]:
1. Set a timer for 5–10 minutes.
2. Write without stopping or correcting.
3. Reread and underline one phrase.
4. Talk about that phrase, or shape it into a few lines.
Example language (illustrative): "Keep the pen moving, even if it's 'I don't know what to write.'"
Watch for: Free writing gives the least containment. Avoid it in early trauma work and with people who tend to spiral into rumination. [synthesis]

4.14 Found poetry

Purpose / when: Listed among current techniques [source: GoodTherapy]. It gives distance and lowers performance pressure, which helps clients who say "I can't write." [synthesis]
Steps [synthesis]:
1. Give printed material: magazines, a leaflet, or the client's own earlier journal.
2. The client picks out words or phrases.
3. They arrange them into a short poem.
4. Discuss why these words and this order.
Example language (illustrative): "Circle any words that jump out, then arrange them so they say something true for you."
Watch for: Source text with triggering content. If the client uses their own clinical letters or records, discuss privacy first. [synthesis]

4.15 Haiku and short fixed forms

Purpose / when:
- Haiku is listed among techniques [source: GoodTherapy].
- A haiku-based technique called SADUPA was studied in palliative care as a four-phase writing method over 4–6 weeks [source: Alfrey et al. citing Santarpia, Dudoit & Paul 2015]. The paper's HAL repository record and its abstract page are not drawn on, so the content of the phases is not given here [uncertain].
- The tight form contains intense feeling, and suits fatigued or medically ill clients. [synthesis]
Steps [synthesis, not the SADUPA protocol]:
1. Offer a three-line shape: an image now, a feeling, an image of something lasting.
2. Don't insist on counting syllables.
3. Read it aloud, then invite a second version.
Example language (illustrative): "Just three short lines: something you can see from your bed, how it feels, and something that stays."
Watch for: Fatigue. Allow dictation. [synthesis]

4.16 Structured journaling

Purpose / when: Gives continuity between sessions, and helps the client process reactions and track patterns [source: GoodTherapy; Mazza & Hayton; Ramsey-Wade & Devine].
Steps [synthesis]:
1. Agree how often and how long, such as 10 minutes three times a week.
2. Give two or three fixed prompts covering an event, a feeling and something that helped.
3. Agree what will be brought to session: the client chooses an excerpt, and the whole journal is never required.
4. Agree where the journal is kept (see 4.28).
Example language (illustrative): "You don't have to show me the journal. Just bring one line you'd like us to look at."
Watch for:
- Rumination loops, where entries rehearse the same distress. If so, add a closing prompt ("one thing I can do next"). [synthesis]
- Non-completion: see Section 5.

4.17 Unsent letter

Purpose / when: An alternative when poetry feels too hard [source: EBSCO]. A core E form in Mazza's model, and the basis of the S ritual in 4.21 [source: Mazza & Hayton; NASW News]. Use it for unfinished business with a deceased, absent or harmful person. [synthesis]
Steps [synthesis]:
1. Name the addressee.
2. Agree the letter will not be sent, unless later decided otherwise in therapy.
3. Write for 10–15 minutes.
4. Choose: read it aloud, summarise it, or keep it private.
5. Decide what happens to the letter: keep, store with the therapist, or ritual (4.21).
Example language (illustrative): "This letter is for you, not for them. Say what never got said."
Watch for:
- Letters to a perpetrator can bring up strong anger or fear. Use only when the client is stable and it fits the trauma pacing plan (4.26). [synthesis]
- Never pressure the client to send a letter or confront someone. [synthesis]

4.18 Narrative and story writing

Purpose / when: Mazza lists narrative among E techniques, and stories within the S dimension [source: Mazza FSU outline; Mazza & Hayton]. Use it to reorder life events, and for clients who prefer prose. [synthesis]
Steps [synthesis]:
1. Choose a chapter or turning point.
2. Write it in third person first, if distance is needed.
3. Add a "what came next" or "what I know now" ending.
Example language (illustrative): "Write it as if about a character called 'she' or 'he'. We can bring it closer later if you want."
Watch for: Third person can turn into avoidance. Over time, invite the client to try first person for short passages. [synthesis]

4.19 Two-column list

Purpose / when: Chavis uses a two-column list headed with what energises and what drains the person [source: NASW News]. Use it for stress, burnout and caregiver work. [synthesis on when]
Steps:
1. Draw two columns and fill both. [source]
2. Then pick one item from each column and turn them into paired lines or a short poem. [synthesis]
Example language (illustrative): "Left side, what fills you up; right side, what drains you. Then we'll make two lines out of them."
Watch for: A drained column that heavily outweighs the other may point to depression or caregiver overload. Assess it rather than just writing about it. [synthesis]

C. Symbolic/ceremonial (S)

4.20 Metaphor work (creating and exploring metaphors)

Purpose / when: Metaphors carry feelings that are hard to state directly and make change easier to picture. Discussing the metaphors that emerge is the S step after writing. [source: Mazza FSU outline; Alfrey et al.; EBSCO] One online loss workshop used metaphor throughout as its main way of expressing feelings. [source: Lets Reimagine workshop]
Steps [synthesis]:
1. Notice a metaphor in the client's speech or writing, or invite one ("If this feeling were weather / an animal / a place…").
2. Explore it inside the metaphor ("How big is it? What does it need?").
3. Invite change inside the metaphor ("What would make the fog thin a little?").
4. Only then link back to life.
Example language (illustrative): "You called it 'a stone in my pocket.' How heavy is it today? Has it ever been lighter?"
Watch for:
- Don't rush to translate the metaphor. Staying inside it is often what makes it workable. [synthesis]
- Signs it is working: the client changes the metaphor themselves over the weeks. [synthesis]

4.21 Letter to the deceased and a release ritual

Purpose / when: Grief and loss. Mazza gives the example of writing a letter to a person who has died and then burning it, adapted to the client's culture. [source: NASW News] A ritual for death and loss is the model example of the S dimension. [source: Mazza & Hayton]
Steps:
1. The client writes the letter (as in 4.17).
2. Ask about cultural and religious practice around the dead, and agree a form of release that fits it: burning, burial, keeping it in a box, reading it at a graveside, or another choice the client names.
3. Prepare the setting safely (see the materials notes at the start of Section 4).
4. Carry out the act with a short spoken intention.
5. Debrief. [source: NASW News for the letter-and-burn example and cultural respect; steps 2–5 synthesis]
Example language (illustrative): "What would feel right to do with this letter, given how your family marks a death?"
Watch for:
- Fire safety.
- Rituals that clash with the client's beliefs.
- Clients who later regret destroying the letter: offer to photograph or copy it first. [synthesis]

4.22 Hand-outline legacy ceremony (group)

Purpose / when: Grief groups. Members trace a hand outline, list the qualities the deceased person left behind, and post them up for a group ceremony. [source: NASW News, Mazza]
Steps:
1. Each member traces their hand.
2. They write the person's qualities or gifts inside it.
3. The hands are posted together on a wall or board.
4. Each member names one quality aloud. [source for steps 1–3; the naming step is synthesis]
Example language (illustrative): "Inside your hand, write what they handed on to you."
Watch for:
- Mixed or abusive relationships with the dead person. Allow "what I choose to keep" or "what I choose to put down" instead. [synthesis]
- Get consent before displaying names (4.28).

4.23 Reading one's own work aloud, recitation and performance

Purpose / when: The S dimension includes performance and recitation, and sharing writing aloud is a common S step. Use it to give the client's voice a witness. [source: Ramsey-Wade & Devine; Alfrey et al.; Mazza & Hayton]
Steps [synthesis]:
1. Ask permission to read.
2. The client chooses whether to read it themselves, have the therapist read it, or have it read silently.
3. Listeners respond first with what they heard or what stayed with them, not with critique or advice.
Example language (illustrative): "Would you like to read it, have me read it, or keep it for now?"
Watch for:
- Shame afterwards, and a vulnerability hangover after reading.
- In groups, set a no-critique rule. [synthesis]

4.24 Anthology or group book as an ending ritual

Purpose / when: Closing a group course. The review notes ending with a ritual such as creating an anthology. [source: Alfrey et al.]
Steps [synthesis]:
1. In the second-to-last session, each member picks pieces to include.
2. Agree how names are credited: full name, initials, pseudonym or anonymous.
3. Agree who receives copies.
4. Present the book at the final session with a short reading.
Example language (illustrative): "Pick one or two pieces you'd like in our booklet, and tell me how you'd like your name to appear, if at all."
Watch for:
- On one ward, a book of group poems was left in a lounge where new patients read it, and consent was not discussed in the source [source: Ramsey-Wade & Devine]. Never do this without each author's informed consent (4.28). [synthesis]

4.25 Holding the group between sessions

Purpose / when: Continuity, and showing members they are held in mind [source: Ramsey-Wade & Devine].
Steps:
1. After each session, type up the collaborative poem.
2. Choose texts for next time based on the discussion.
3. Open the next session with the typed poem. [source: Ramsey-Wade & Devine]
Example language (illustrative): "Here's the poem you made last week. Read it through and see if it still fits."
Watch for: Store and transport the typed poems as clinical material (4.28). [synthesis]

D. Writing safety procedures

4.26 Pacing trauma disclosure through writing

Purpose / when: To let traumatic material come out gradually and under the client's control.
- Bowman & Halfacre describe a sexually abused adolescent who used poetry to rehearse painful experiences before disclosing them in therapy. [source: Alfrey et al. citing Bowman & Halfacre 1994]
- Unwanted feelings may be easier to express in poetry. [source: Alfrey et al.]
- Mazza warns against texts that bring up unintended trauma. [source: NASW News]
- The graded ladder below is [synthesis], drawing on standard phase-based trauma practice.
Steps [synthesis]:
1. Before any trauma-focused writing, check stabilisation: current safety, a grounding skill the client can use, and their window of tolerance.
2. Work up a distance ladder, letting the client set the speed:
  - a published poem about a nearby theme;
  - metaphor only ("if it were a place…");
  - third-person or fictional writing;
  - first-person writing about the edges of the event (before, after, what helped);
  - first-person writing about the event itself, only if clinically indicated and within a trauma-focused treatment plan.
3. Agree a stop signal and a time limit, such as 10 minutes.
4. The client always chooses whether to share the writing.
5. Record what was disclosed and act on safeguarding duties (Section 5).
- The epigraph of one source review is Dickinson's "Tell all the truth but tell it slant", a short poem on telling truth indirectly. It can serve as a frame for permission to disclose at an angle. [source: Ramsey-Wade & Devine for the poem; use as a prompt is synthesis]
Example language (illustrative): "You don't have to write what happened. Write the weather that day, or what the room looked like after. You decide how close we get."
Watch for:
- Flooding: shaking, dissociation, the client's writing breaking down, or a sudden flat tone.
- Over-disclosure in a group that the client regrets.
- Signs it is working: the client moves one rung up the ladder by choice and stays regulated. [synthesis]

4.27 Closing after distressing writing

Purpose / when: At the end of every session where writing has stirred strong feeling. Stimulus poems and writing can bring on immediate emotional reactions and re-living of memories, and participants report "mixed emotions." [source: Alfrey et al.] Mazza's group format closes with a shared poem that summarises the session, and the review describes closing rituals. [source: Ramsey-Wade & Devine; Alfrey et al.] The closing steps below are [synthesis].
Steps [synthesis]:
1. Stop new material at least 10–15 minutes before the end.
2. Shift to a containing task: a collaborative closing line, a "one thing I'm taking with me" stem, or a short hopeful text (hope is a selection criterion in EBSCO).
3. Ground the client: feet on the floor, name objects in the room, slow breathing, holding something cool.
4. Agree what happens to the page: fold it, seal it in an envelope, or leave it with the therapist (a "container").
5. Check the client's rating of distress and arousal against the start of the session.
6. Go over the plan for the next 24 hours and who they can contact, and check risk if self-harm or suicidal thoughts came up.
7. In groups, check in briefly one-to-one with anyone still distressed, and do a short follow-up call if needed.
Example language (illustrative): "Let's put the pen down. Fold the page, it can wait here till next week. Now tell me three things you can see in this room."
Watch for:
- The client leaving dissociated.
- Writing alone at home straight after the session.
- The urge to keep writing at night: agree a time limit and a closing ritual for home writing. [synthesis]

4.28 Privacy agreement for written material

Purpose / when: At the start of therapy and before any sharing, display or publishing. Sources mention patient writing being published in hospital newsletters, and a ward poem book that was read by others. [source: NASW News; Ramsey-Wade & Devine] Neither source gives a consent procedure [uncertain]. The steps below are [synthesis].
Steps [synthesis]:
1. Explain whose the writing is. The client owns it and keeps the original unless agreed otherwise.
2. Explain what goes into the clinical record: a summary, or a copy only with consent and where your setting requires it. Explain that what is written is subject to the same limits of confidentiality as speech, including safeguarding and risk.
3. Agree storage: the client's home (think about who might read it there), the therapist's locked file, or a secure digital service. No personal email or shared drives.
4. For groups: a ground rule that what is read in the room stays in the room, and members may not photograph or copy others' work.
5. Get separate, written, withdrawable consent for any display, anthology, newsletter, research or social-media use, with the choice of name or pseudonym.
6. For online sessions: agree no recording or screenshots, and use the chat or a secure upload for writing.
Example language (illustrative): "What you write is yours. If anything in it tells me someone is at risk, I'd need to act, same as if you'd said it. Nothing gets shared beyond this room without your written OK."
Watch for:
- Clients at risk from household members reading their journals, such as in domestic abuse. Offer to store their writing in therapy. [synthesis]

4.29 Access adaptations

Purpose / when: Make the method usable regardless of literacy, language, disability or cognition. The 3rd edition adds material on people with disabilities, minorities and other special populations [source: Routledge]. Progressed dementia may be a contraindication [source: Alfrey et al. citing Deshpande 2010]. Specific adaptations are [synthesis].
Steps [synthesis]:
- Dictation and scribing.
- Voice recording.
- Large print and audio texts.
- Texts in the client's first language, or bilingual writing.
- Picture prompts and sensory objects (4.7) for people with cognitive impairment.
- Shorter tasks and seated, low-effort formats for fatigue.
- Easy-read stems for people with learning disability.
- Song or spoken-word options for those alienated by "poetry".
Example language (illustrative): "You can say it and I'll write it down exactly as you say it."
Watch for:
- The client feeling that school-style poetry is being judged. A poor earlier relationship with poetry was linked to the only early termination reported in the review [source: Alfrey et al. citing Reiter 1994].

5. Handling problems

The sources give little guidance on handling problems. Items without a source tag are [synthesis].

Screening and contraindications

Not suitable during active psychosis until the person is medicated and in treatment [source: NASW News, Chavis]. Metaphor may confuse clients with thought disorders, so use concrete poems with them [source: Furman et al. 2002].
Progressed dementia may be a contraindication [source: Alfrey et al. citing Deshpande 2010].
Also screen for [synthesis]:
- acute suicidality without a safety plan;
- current dissociative instability;
- an ongoing abusive relationship where written material could be found;
- severe literacy shame;
- acute grief within days of a death, where reading and ritual can wait.
Assessment rule [synthesis]:
- Client writing is clinical material, not a diagnostic test.
- Never treat themes, images or style in a poem as evidence of abuse or disorder. No validated diagnostic use of client poetry is described in the sources [uncertain].
- Explore what was written. Assess any concern through your standard clinical and safeguarding procedures.

Client says "I'm not a writer" or "I hate poetry"

A poor earlier relationship with poetry preceded the only early termination reported in the review [source: Alfrey et al.].
Responses [synthesis]:
- Use song lyrics or film (4.5), found poetry (4.14), lists (4.19) or dictation (4.29).
- Drop the word "poem" and call it "a few lines."
- Make clear that no one is grading.

Stuck: flat or intellectual responses

Responses [synthesis]:
- Switch from talking about the text to using one of its lines as a stem (4.8).
- Ask what the client would change in the poem (4.3).
- Use a sensory object (4.7) or a metaphor question (4.20).
- Swap the text. Mazza says no poem works for everyone, but don't drop a poem too soon [source: NASW News].

Resistance and defensiveness

Indirect work may suit resistant or highly defended clients [source: Ramsey-Wade & Devine].
Responses [synthesis]:
- Stay in R (published texts) longer.
- Allow writing about "a character."
- Never ask for the client's writing to be handed over.
- Name the right to pass.

Overwhelm, flooding or retraumatisation during or after writing

Stimulus texts can bring on re-experiencing [source: Alfrey et al.].
Responses [synthesis]:
- Stop the task, ground the client and switch to a containing text (4.27).
- Afterwards, review the pacing ladder (4.26) and step down a rung.
- Check that the text you chose did not contain the client's specific trigger (Mazza's caution, NASW News).
- If flooding keeps happening, pause trauma-focused writing and go back to stabilisation.

Distress after the session (writing at home)

Responses [synthesis]:
- Agree home-writing rules: a time limit, writing in daylight, a closing line, and a named person or crisis contact.
- If self-harm or suicidal content appears in writing, assess risk by your service's standard procedure, just as you would for spoken content. Update the safety plan, including storing or removing means at home where relevant.

Non-adherence with journals or homework

Responses [synthesis]:
- Shrink the task to one line a day, or a voice note.
- Ask what got in the way: privacy at home, time, or fear of what might come out.
- Offer in-session writing instead.

Ruptures

Possible ruptures [synthesis]:
- The client feels misread by your choice of poem ("Why give me this?").
- Their writing was mishandled, for example shared, lost or criticised.
- A group member critiqued their work.
Responses [synthesis]:
- Name it, take responsibility for how the text was chosen, and ask what would have fitted better.
- Repair breaches of the privacy agreement (4.28) openly. Report them as your setting requires.

Group problems

Possible problems [synthesis]:
- One member monopolising the reading time.
- Members comparing quality or giving critique.
- One person's trauma disclosure distressing others.
Responses [synthesis]:
- Set ground rules at the start [source: Alfrey et al.]: no critique, the right to pass, limits on how much detail of traumatic events is shared, and confidentiality.
- Redirect graphic disclosure to individual time.
- Keep groups small: one workshop model capped them at 12 [source: Lets Reimagine workshop].

Children and young people

The 3rd edition has chapters on children, early adolescents, adolescents and young adults [source: Routledge TOC]. A case study describes a sexually abused adolescent using poetry before disclosure [source: Alfrey et al.].
Responses [synthesis]:
- Get the child's assent and the carer's consent.
- Explain confidentiality limits at a level the child understands.
- Use play-like forms such as collaborative poems (Seiden, per Alfrey et al.), acrostics and object prompts.
- Never show a child's writing to parents or carers without the child's agreement, except for safeguarding.
- Any disclosure of abuse in writing triggers your mandatory-reporting or safeguarding procedure. Do not question the child to gather more detail beyond what your procedure allows.

Cultural and spiritual fit

Mazza asks for cultural respect in ritual [source: NASW News]. The 3rd edition has a chapter on spirituality [source: Routledge TOC].
Responses [synthesis]:
- Ask before using religious texts or rites.
- Do not perform or copy sacred ceremonies from traditions that are not the client's own. Support the client's own community practices instead.

Scope and credentials

Mazza warns about scope of practice [source: Alfrey et al.].
Responses:
- If you are not IFBPT-trained, describe your work as "using poetry and writing within psychotherapy," not as "poetry therapy" [source: HPN].
- Get supervision from someone experienced in therapeutic writing. Look after yourself too: see Mazza's "Who heals the healers?" [source: NASW News].

Not covered in the sources [uncertain]:

IFBPT's current published training standards. CAPF was verified only through O*NET, and the CPT and registered-level requirements only through secondary sources.
The text of Mazza's book, including his procedures for the cluster poem and the dyadic poem. Only its contents page, his workshop outline and the Mazza & Hayton paper are drawn on.
The full text of Hynes & Hynes-Berry. Its four stages are verified only from secondary summaries (Kosonen 2019; Shah & Sanu 2023).
Leedy's own books (the isoprinciple is cited through Franks 1974), and the SADUPA paper (blocked).
Formal criteria for moving between dimensions.
Any published protocol for distress management, closure or privacy.

Sources

Web sources:

Further web sources:

Further books cited:

Leedy, J. J. (1969). Poetry Therapy: The Use of Poetry in the Treatment of Emotional Disorders. (Isoprinciple, pp. 67–68, cited through Franks 1974.)
Lerner, A. (1981), as cited in Furman et al. 2002 (definition and seating).
Houlding, S. & Holland, P. (1988), as cited in Furman et al. 2002 (blank-phrase poems).

Books and papers cited:

Mazza, N. (2022). Poetry Therapy: Theory and Practice (3rd ed.). Routledge.
Mazza, N. (2017). Poetry Therapy: Theory and Practice (2nd ed.). Routledge. (As cited in Alfrey et al.)
Mazza, N. (2003). Poetry Therapy: Theory and Practice. (As cited in Ramsey-Wade & Devine; publisher [uncertain].)
Hynes, A. M. & Hynes-Berry, M. (1986; 3rd ed. 2012, North Star Press, with a new introduction by Peggy Osna Heller). Biblio/Poetry Therapy – The Interactive Process: A Handbook. (The four-stage process is on pp. 31–48, as cited in Kosonen 2019. A 2012 edition is also cited in Mazza & Hayton.)
Bowman, D. O. & Halfacre, D. L. (1994). Poetry therapy with the sexually abused adolescent: a case study. The Arts in Psychotherapy, 21(1). (As cited in Alfrey et al.)
Golden, K. M. (2000). The use of collaborative writing to enhance cohesion in poetry therapy groups. Journal of Poetry Therapy, 13(3). (As cited in Alfrey et al.)
Santarpia, A., Dudoit, E. & Paul, M. (2015). The discursive effects of the haiku-based SADUPA poetry technique in palliative care. Journal of Poetry Therapy, 28(3). (As cited in Alfrey et al.)
Deshpande, A. (2010). Effectiveness of poetry therapy as an adjunct to self-psychology in clinical work with older adults: a single case study. Journal of Poetry Therapy, 23(1). (As cited in Alfrey et al.; author initial [uncertain].)
Gross, P. (1998). The Wasting Game. (Poem series, as cited in Ramsey-Wade & Devine.)

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