Bibliotherapy

overview

The Greek philosopher Aristotle famously believed that literature was “medicine for the soul,” and the ancient Romans recognized that there was a relationship between reading and its ability to evoke catharsis, or emotional release.[1] While the earliest proponents of the healing effects of literature had little proven evidence for their beliefs, the concept of bibliotherapy is now widely viewed as an effective therapeutic approach which employs books and other forms of literature, typically alongside more traditional therapy modalities, to support a patient’s mental health. The American Counseling Association formally describes bibliotherapy as involving the use of books and other media to facilitate both normal development and clinically significant problems.[2]

Bibliotherapy is rooted in the idea that literature, as a reflection of human existence, leads those involved to reflect on themselves and their environment. Described by Shrodes (1950) as a process of dynamic interaction between the personality of the reader and imaginative literature, bibliotherapy has the capacity to confront individuals with their emotions, values, feelings, and conflicts.[3] Moreover, reading may offer a plethora of benefits to oneself including improving self-esteem, self-awareness, and feelings of self-efficacy (i.e., an individual's belief in his or her capacity to execute behaviors necessary to produce specific performance attainments).[4] As more empirical evidence and contemporary research findings come into light, a diverse body of practitioners including school media specialists, counselors, librarians, and teachers have incorporated bibliotherapy into their programs.[5]

History

Established in 1983, the International Federation for Biblio/Poetry Therapy states, “Races, cultures, religions, and groups across the globe have identified with both spoken and written word as a means of recording history and expressing emotion as well as a mode of healing since the dawn of humankind.”[6] Dating back to 100 AD, Greek physician Soranus prescribed reading tragedy for manic patients and comedy for depressed patients. Outside of Greece, other societies began to associate literature with medicine. In 1272, the Koran was part of medical treatment in Cairo, Egypt, and the medieval Abby Library of St. Gall in Switzerland even bears the inscription: ''Medicine Chest for the Soul.”[7] By the eighteenth century, most psychiatric hospitals in Europe included a library. Around the same time period, bibliotherapy was first introduced in the US in the Pennsylvania Hospital, an institution that prescribed reading and writing treatments for mentally ill patients, even documenting the work in their newspaper, The Illuminator (1751). The first person to officially coin “bibliotherapy” though, was Samuel Crothers in 1916 who used the term in an article for the Atlantic Monthly, suggesting the use of books for patients to help them understand their problems.

The prevalence of bibliotherapy increased over the next few years, specifically in the context of World War I as many patients needed assistance healing from traumatic war experiences. In fact, the American Red Cross added libraries to several army hospitals and a substantial amount of bibliotherapy research and literature was provided from the Veterans Administration.[8] By the 1950s, much more bibliotherapy research was being conducted in hospital settings. Ruth Tews, a hospital librarian at the Mayo Clinic, carried out research with several prominent physicians and wrote a multitude of articles. Soon after, in 1964, the first national bibliotherapy workshop was held, sponsored by the National Institute of Mental Health and the American Library Association. Since then, many more organizations like the International Federation for Biblio/Poetry Therapy (IFBPT) have been established and more research has been published, supporting the use of bibliotherapy in clinical settings for mental health as well as other educational and developmental domains.

Types of Bibliotherapy

Bibliotherapy is divided into two distinct practice domains:[9,10]

Developmental: This type of bibliotherapy is primarily used by educators, librarians, and healthcare workers in community settings to address transitions for individuals with no known mental health disorders. For example, developmental bibliotherapy may help children or adults address common life challenges, such as bullying.

Clinical: This type of bibliotherapy is also known as therapeutic bibliotherapy. It is utilized by mental health practitioners and addresses emotional-behavioral problems to meet therapeutic goals. Typically involving deliberate and planned interventions, this therapy treats those with diagnosed mental disorders, using books in a psychiatric or mental health paradigm.

Theoretic and Therapeutic Processes

Parallel in both substance and function to the primary phases of psychotherapy, Carolyn Shrodes (1950) developed the first theoretical model from which current bibliotherapy expansions and applications have been derived. In outlining the rationale behind bibliotherapy, she used the phrase, “shock of recognition” to express the feeling a reader experiences when beholding himself or those close to him in a story or other piece of literature.[11] Shrodes pointed to identification as a central part of bibliotherapy. As reading is a vicarious experience, bibliotherapy allows readers to share a character’s experience, their story and their struggles to ultimately gain valuable insight into their own situation and learn effective ways to address their problems.[12] Though Shrodes conceptualized the initial model, other researchers have contributed key principles which are integrated into most contemporary bibliotherapy practices. Taking an interest in this therapy for use in educational settings, Afolyana (1992) built upon Shrodes initial three part construct, introducing the idea of universalization to form the existing four-part bibliotherapy model.[13] A few years later, Hynes & Hynes-Berry (1994) developed an interactive model which emphasized relationship building, assessment of client interest, and reading skills. Bibliotherapy became much more flexible with this introduction. In each session, variations may include client-initiated to counselor-initiated, structured to unstructured, directive to non-directive and more-facilitated to less-facilitated; nevertheless, the general process of clinical bibliotherapy occurs in four distinct stages.

Four-Part Structure of Bibliotherapy:[14,15]

Identification: The reader creates a bond with the character in the text they most identify and affiliate with, often sharing a similar situation, goal and/or problem with their chosen character.
Catharsis: The reader experiences the character’s complex emotions, struggles and reflective internal dialogues conveyed through the written text.
Insight: The reader, having identified similarities of the text to real life, decides to apply the character’s problem solving and ideas to their own life.
Universalization: The reader realizes their struggles are not isolated, and they are not alone. The reader can incorporate what they have learned into their own life and generalize the character’s situation to other people, cultures, contexts and situations.

Current Relevance

Compared to previous decades, bibliotherapy holds much more current relevance to the field of modern psychiatry and psychology through a plethora of empirical studies being conducted. With its practices being evaluated and studied in more systematic and measurable ways, bibliotherapy has been shown effective as an adjunct to traditional therapy, especially for depressed children and adolescents. The CDC (2022) states that the most commonly diagnosed mental disorders in children are ADHD, anxiety problems, behavior problems, and depression.[16] Accordingly, many researchers in the past decade have focused on the viability of bibliotherapy to be used as an interventional tool to address anxiety, aggression, and depression in children and adolescents.

In a study by Newman (2015) examining the potential of bibliotherapy for aggressive elementary children, it was found that eight sessions of interventional bibliotherapy was associated with notable decreases in observed aggressive behaviors as well as decreases in teachers’ ratings of aggression and/or social problems.[17] Researchers Lyneham & Rapee (2006) were interested in the effect of bibliotherapy for children with anxiety disorders, particularly those with parents from remote and rural communities. One hundred children were provided therapist-initiated telephone or email bibliotherapy sessions in a randomized trial; results showed that 79% of children were free of anxiety disorder post-treatment.[18] In a comparative efficacy study of bibliotherapy for both depression and anxiety disorders, Yuan et al. (2018) looked at eight studies with 979 participants. Researchers found that bibliotherapy was significantly more effective than the control conditions in reducing the symptoms of depression or anxiety; moreover, upon performing a subgroup analysis for efficacy outcomes in different categories, bibliotherapy was shown to be most effective in depressive adolescents.[19]

Though bibliotherapy is commonly studied in the context of children and adolescents, one recent study from the Institute of Psychiatry and Neurology in Warsaw, Poland examined bibliotherapy in a novel context. Kasperek-Zimowska et al. (2021) were interested in the specificity of the use of bibliotherapy as an element of psychiatric rehabilitation in a group of patients suffering from schizophrenia, a disorder often characterized by disordered thoughts and a tendency toward delusional thinking. Through structured bibliotherapy sessions and feedback from various patients, researchers reported that a number of patients showed increased engagement in various ways (e.g., talking more about themselves, fluently expressing opinions, and participating in conversations with others). Researchers emphasize the positive effects observed in their study and encourage further research as bibliotherapy could be effective in treating other types of thought disorders.[20]

Efficacy

Bibliotherapy has historically been critiqued for being too broad a term, lacking a strong empirical basis that would allow its widespread use in interventional and clinical settings. One early critique of bibliotherapy literature dating back to 1966 stated, “Bibliotherapy offers no panacea, but with proper scientific study may help many patients.”[21] Even with the new body of evidence within current literature, this sentiment is still around many years later and many researchers are interested in assessing the efficacy and validity of bibliotherapy as a science.

A meta-analysis of bibliotherapy studies by Marrs (1995) identified therapist contact as a factor in bibliotherapy’s effectiveness. Though therapist contact during bibliotherapy did not seem to relate to effectiveness, there was evidence that certain types of issues including weight loss and anxiety reduction responded better with increased therapist contact. This may point to the value of bibliotherapy as a low-cost, accessible option for those in remote areas who do not have access to in-person therapy sessions.[22] In another, more recent, systematic review of randomized clinical trials, Gualano et al. (2017) looked at ten articles examining bibliotherapy for depression, involving a total of 1347 patients. The analysis showed that after long-term period follow-ups, six studies including adults, reported a decrease of depressive symptoms, while four studies including young people did not show significant results.[23] Similar to the Marrs study, this study concludes that bibliotherapy represents a cheap and time-saving option, because it would require a minimal therapist contact, but recommends that further studies be conducted to strengthen the evidence of bibliotherapy's efficacy.

In a particularly relevant and recent meta-analysis study of bibliotherapy as a non-pharmaceutical intervention to enhance mental health in response to the COVID-19 pandemic, Monroy-Frausto et al. (2021) stated that bibliotherapy can and should be considered when developing public policies to help take care of the mental health of those affected by the pandemic. Additionally, this study examined the linkage between values such as autonomy and justice to bibliotherapy effects. The results showed that both autonomy and justice linked with positive results in bibliotherapy because this type of therapy could promote empowerment, decision-making, and problem-solving.[24] Bibliotherapy is certainly an accessible and economic option, despite the fact that research does not yet show benefits surpassing that of other psychological treatments.

Further Research & Limitations

There are some guidelines and cautions that therapists must take before applying bibliotherapy in a clinical or educational setting. According to Pehrsson & McMillen (2007), each book should be read before using or recommending it to clients. It is also recommended that therapists choose each text carefully to be sure it is current, credible and most importantly that it is relevant to a client’s needs. Moreover, both counselors and therapists should also take caution with clients that have reading/learning disorders or extreme anxiety. The authors recommend that these clients should never be asked to read orally to others without preparation by practicing first.[25]

Additionally, the Monroy-Frausto et al. (2021) study points to a few key aspects of bibliotherapy that need further research. The types of sessions bibliotherapy consists of vary from in-person to telephonic contact or email, and most studies included in the analysis were not specific in mentioning the type of sessions in which therapy was offered. Thus, it would be important to examine the efficacy of online contact compared to in-person contact as bibliotherapy may present a novel mental health intervention for those who are critically ill during a pandemic or high flu-season and don’t have access to adequate health resources. Another feature of bibliotherapy is the type of material used in each therapy session, whether in the form of books or booklets. Approximately half of the studies in the analysis used problem-specific books to offer therapy; however, the structure of such materials is not clear and cannot easily be reproduced. Additionally, more studies on the different types of literature whether fiction, non-fiction or other genres should be conducted in order to gain a more complete understanding of how content connects and relates to efficacy in bibliotherapy practices.[26] Regardless of the existing gaps in literature currently, bibliotherapy is emerging in its capacity to help a variety of people who may be geographically and socioeconomically disadvantaged with their emotional well-being and mental health. Reading books has long been recognized as a means to help individuals deal with concerns and can offer strategies specific to developmental issues. Although empirical research is lacking, few would disagree that stories have the ability to affect human emotions.

If you or someone you know would like to learn more about bibliotherapy and how to incorporate it into your own life, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.

Contributed by: Kaylin Ong

Editor: Jennifer (Ghahari) Smith, Ph.D.

references

1 Salup, B. J., & Salup, A. (1978). Bibliotherapy: An Historical Overview. ERIC Institute of Education Sciences. https://eric.ed.gov/?id=ED200896

2 Pehrsson, D.-E., & McMillen, P. (2007). Professional Counseling Digest Bibliotherapy: Overview and Implications for Counselors. https://www.counseling.org/resources/library/ACA%20Digests/ACAPCD-02.pdf

3 Shrodes, C. (1955). Bibliotherapy. The Reading Teacher, 9(1), 24–29. http://www.jstor.org/stable/20196879

4 Carey, M., & Forsyth, A. (2009). Self-Efficacy. Https://Www.apa.org. https://www.apa.org/pi/aids/resources/education/self-efficacy#:~:text=Self%2Defficacy%20refers%20to%20an

5 Salup & Salup (1978)

6 History. (n.d.). International Federation for Biblio Poetry Therapy. Retrieved August 28, 2023, from https://ifbpt.org/history/

7 Eich, Carla Marie, "Bibliotherapy : background, application and research" (1999). Graduate Research Papers. 589. https://scholarworks.uni.edu/grp/589

8 Ibid.

9 Pehrsson, D.-E. (2006, July). Benefits of Utilizing Bibliotherapy within Play Therapy. ResearchGate. https://www.researchgate.net/publication/273961304_Benefits_of_Utilizing_Bibliotherapy_within_Play_Therapy

10 Pehrsson & McMillen (2007)

11 Shrodes (1955)

12 Pehrsson (2006)

13 Afolayan, J. A. (1992). Documentary Perspective of Bibliotherapy in Education. Reading Horizons: A Journal of Literacy and Language Arts, 33 (2). https://scholarworks.wmich.edu/reading_horizons/vol33/iss2/5

14 Bibliotherapy | Psychology Today. (n.d.). Www.psychologytoday.com. https://www.psychologytoday.com/us/therapy-types/bibliotherapy

15 Monroy-Fraustro, D., Maldonado-Castellanos, I., Aboites-Molina, M., Rodríguez, S., Sueiras, P., Altamirano-Bustamante, N. F., de Hoyos-Bermea, A., & Altamirano-Bustamante, M. M. (2021). Bibliotherapy as a Non-pharmaceutical Intervention to Enhance Mental Health in Response to the COVID-19 Pandemic: A Mixed-Methods Systematic Review and Bioethical Meta-Analysis. Frontiers in Public Health, 9. https://doi.org/10.3389/fpubh.2021.629872

16 CDC. (2022, April 19). Data and Statistics on Children’s Mental Health. Centers for Disease Control and Prevention. https://www.cdc.gov/childrensmentalhealth/data.html#ref

17 Newman, K., Newman, & Kari. (2015). Bibliotherapy as an Intervention for Aggressive Elementary Children Part of the Counseling Psychology Commons, and the Special Education and Teaching Commons BYU Scholars Archive Citation. https://scholarsarchive.byu.edu/cgi/viewcontent.cgi?article=6778&context=etd

18 Lyneham, H. J., & Rapee, R. M. (2006). Evaluation of therapist-supported parent-implemented CBT for anxiety disorders in rural children. Behaviour Research and Therapy, 44(9), 1287–1300. https://doi.org/10.1016/j.brat.2005.09.009

19 Yuan, S., Zhou, X., Zhang, Y., Zhang, H., Pu, J., Yang, L., Liu, L., Jiang, X., & Xie, P. (2018). Comparative efficacy and acceptability of bibliotherapy for depression and anxiety disorders in children and adolescents: a meta-analysis of randomized clinical trials. Neuropsychiatric Disease and Treatment, Volume 14, 353–365. https://doi.org/10.2147/ndt.s152747

20 Kasperek-Zimowska, B. J., Bednarek, A., Giguere, M., Orłowski, W., & Malewicz-Sawicka, M. (2021). The specificity of the use of bibliotherapy as an element of psychiatric rehabilitation in a group of patients suffering from schizophrenia. Advances in Psychiatry and Neurology/Postępy Psychiatrii i Neurologii, 30(4), 278-286. https://doi.org/10.5114/ppn.2021.111946

21 Favazza, A. R. (1966). Bibliotherapy: a critique of the literature. Bulletin of the Medical Library Association, 54(2), 138–141. https://pubmed.ncbi.nlm.nih.gov/5325817/

22 Marrs, R. W. (1995). A meta-analysis of bibliotherapy studies. American Journal of Community Psychology, 23(6), 843–870. https://doi.org/10.1007/bf02507018

23 Gualano, M. R., Bert, F., Martorana, M., Voglino, G., Andriolo, V., Thomas, R., Gramaglia, C., Zeppegno, P., & Siliquini, R. (2017). The long-term effects of bibliotherapy in depression treatment: Systematic review of randomized clinical trials. Clinical Psychology Review, 58, 49–58. https://doi.org/10.1016/j.cpr.2017.09.006

24 Monroy-Fraustro et al., (2021)

25 Pehrsson & McMillen (2007)

26 Monroy-Frausto et al., (2021)