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Over the years, we found that many of the clients in our geriatric continuing treatment program were very resistive to using the conventional verbal therapies to make self-disclosures. However, these same clients were telling us in indirect ways that they needed to talk about their feelings in more than a superficial manner. As the nurse clinician in the program, my area of training and expertise lay within the verbal therapy modality; however, as administrator of the program, I saw the need for more expressive therapy groups. Unfortunately, because of budget constraints, we were unable to hire additional staff to run such groups.

At that time, I came across Koch's book on teaching poetry writing in a nursing home (Koch, 1977). His premise was that anyone could write poetry and that one never loses the ability to be creative. His methods seemed straightforward and relatively simple to follow. Although a review of the literature did not reveal any articles on poetry writing in a chronically mentally ill geriatric population, we decided to introduce, on an experimental basis, a poetry writing group as a form of expressive therapy to aid selfdisclosure.

Initially, the clients resisted the idea. They viewed poetry in a very limited way and felt that they did not have the ability to write it. Following the format outlined by Koch, our first task was to broaden their view of poetry to include free verse. We read poems written in free verse by wellknown poets as well as poems written by the elderly in Koch's book.

Once the clients understood that poems did not have to rhyme, we went on to compose group poems. In this way, the effort was shared by all and eased the stress of performance anxiety. The format we used was to introduce a feeling such as "love" or "hate" and ask each member of the group to describe it in one or two words. A staff member recorded the responses for all to see. Everyone's responses were valued and used. When the poem was completed, we read it back to the group and asked for reactions. Because everyone had participated in composing the poem, there was a high level of involvement in the discussion that followed.

Another technique for writing group poems, recommended by Koch, was the use of a repetitive phrase, such as "growing old means," to tie the poem together. Each client in the group is asked to complete the phrase and his answer becomes a line of the poem.

Once clients were used to the idea that free verse was a form of poetry and that they could write it, we had them compose their own poems. The general format, which followed Koch's approach, consisted of introducing a topic, discussing it briefly, reading some poems on the topic or introducing props to help stimulate thought, and having the clients write.

In finding topics to write about, we first used Koch's book as a guide. We had clients write about a favorite color, react to music that was played, and talk to the moon and stars. Eventually we branched out to include what was happening in the environment. For instance, when there were many changes going on in the program, the clients wrote about how the changes affected them; when it was raining outside, they wrote about the rain; when a noliday was coming up, they wrote about the holiday. In this way, they were given a chance to get in touch with their feelings about what was happening and to share these feelings with the group.

Once we decided on a topic, we talked it over briefly with the clients. The first response that came from them was often, "oh, no, that's too hard." Therefore, it was important to talk about the topic in general terms to help generate ideas. For instance, we had the clients write one poem in which they pretended that they were spring. First, we had them describe some of the signs of spring, how they could tell that winter was leaving, how it felt to know that spring was coming, and so on. Then we asked them to think of how spring would feel if it were a person, what it would do, what color it would be. Props used were pussy willows, colored Easter eggs, and daffodils. Finally, the clients were given pencils and paper and instructed to write.

Staff members were available to help clients clariiy their thoughts or to take over the mechanics of writing when necessary. It must be stressed that the clients were in charge of composing the poems and that the staff person only assisted in getting the thoughts on paper. After the poems were completed, they were read to the group and the members were encouraged to comment on them. The staff worked hard to create an atmosphere where each poem was valued in its own right. The clients seemed to enjoy the sharing process. They listened attentively while the poems were read and appeared especially pleased when their poem received a favorable reaction. Through creating a poem, clients had a positive sense of accomplishment and, through sharing their poems, they had a feeling of connectedness with the others in the group.

As the poetry writing group developed, we began to see that it was an effective way of getting the clients to share their thoughts and feelings with others. The sessions were structured so that everyone was writing on the same topic. Therefore, they were not as vulnerable as they would be if they brought up the topic themselves, so it was easier to take risks. Also, the clients were always in control of the situation. They could reveal as much or as little as they wanted. The Writing and sharing process had the effect of raising self-esteem and of making the clients feel more connected to each other.

When we introduced poetry writing into the program, we expected very little response from the clients with diagnoses of dementia. However, we were proven wrong. Margaret was receiving treatment for dementia with depression. Her usual interaction with the staff and other clients revolved around asking repetitive questions. She showed very little ability for spontaneous conversations or to pursue any topic in depth. We knew from information received from her family and the residential facility where she lived that she had suffered many traumas in her life; the most recent being the death of her husband. We were at a loss as to how to reach her. We were not sure how many of her symptoms were due to organicity or to depression.

Through poetry writing, Margaret was able to share more of her feelings than by any other means. In "I Never Told Anybody," she was able to relate her concerns about death.

I Never Told Anybody

I never told anybody

How old I was

How many diseases I had

Or where I want to be buried.

In a rambling poem about Christmas, she poignantly stated her struggle with the issue of death:

In another poem, Margaret indicated that she has come to terms with her life. She could not talk directly about the sadness in her life or the struggles she had to endure, but she could hint at it in her poem:

I've done a lot of thinking

And shed a lot of tears

All your incisions heal

And you forget where they were.

Through her poems, Margaret showed the staff another side of herself. She was able to express her thoughts, fears, and wishes on paper in a way that she was unable to do in any other manner. She taught us that even though she had severe cognitive impairments, she still had parts of herself that were connected to reality. The result was that our interactions with her changed. We developed more tolerance for her repetitive questions and saw how she used them to avoid talking about painful topics. We focused on her poems and let her know that we appreciated what she was doing.

Another client who used the poetry group in a positive way was Shirley. Shirley was forced to attend our geriatric program to continue to live in the group home where she was staying. She had been recently hospitalized for a suicide attempt. She was very distrustful of staff and participated as little as possible in the program. However, she agreed to be part of the poetry writing group. She used the group to test us and to tell us just what she thought, as shown in the following poem:

In a sense, she was challenging us with this poem. How were we going to accept it and, thus, her? We accepted it with no questions asked and read it to the rest of the group. The other clients enjoyed the cockiness of it and we all had a good laugh. The poem seemed to break the ice and created a warm feeling about the group.

In her own way and in her own time, Shirley was able to share some of her feelings about the past. Through her poems, she was able to bring up the painful topic of her daughter's death and her own belief that she was "bad." Gradually, her relationship with the staff changed. She began to let her guard down, but not without some reservations as shown by the following poem:

Through her poems, Shirley shared a side of herself that she had never shown before. Poetry writing worked for her because she was allowed to be in control and because she had a topic to focus on. She could not bring up subjects or feelings on her own because there were too many threatening issues that overwhelmed her. She needed to be given a focus and a controlled method of expression.

Poetry writing became an effective therapeutic tool in the program. The clients were able to use it as a nonthreatening vehicle for self-expression. Overall, the quality of the clients' poems varied from session to session. There seemed to be times when the chosen topic brought out deep feelings from all the clients and other times when nothing really happened. Also, the amount of disclosure varied from one session to the next with each individual client. But, in the long run, patterns emerged that aided the staff in gaining better insight into the thoughts and feelings of the clients. These insights were helpful in developing more effective treatment plans.

Although most nurse clinicians have been trained in conventional verbal therapies as treatment approaches, they are not always the most effective methods when working with the chronically mentally ill clients. Poetry writing groups offer an alternative approach to treatment, which can be readily implemented without additional training.