Introduction
As the nascent disciplines of psychiatry and clinical psychology emerged, a tendency to emphasise the role of expertise, whether through the application of biological science or through the lengthy process of mastering a school of psychotherapy, led to diminished cognisance of the role of reading/book prescription in recovery from mental illness and psychological difficulties.
Cohen (Reference Cohen1993), defines bibliotherapy as the use of literature in a therapeutic way. It has also been defined as a process of dynamic interaction between the personality of the reader and literature, an interaction which may be used for personality assessment, adjustment and growth (Russell & Shrodes, Reference Russell and Shrodes1950). Silverberg (Reference Silverberg2003), extensively reviewed the historical background of/literature relating to bibliotherapy and describes two primary types of resources that clinicians can use for bibliotherapy namely; imaginative literature and didactic texts. The first approach to bibliotherapy emphasises the use of imaginative literature to allow expression and exploration of feelings, thoughts or situations that may be difficult or impossible to acknowledge. This includes poetry, memoir, drama, fiction and non-fiction. The didactic approach involves self-help books more directly focused on a particular issue or problem. These books may take a manual or workbook style approach, with exercises and self-completed rating scales prominent. Campbell & Smith (Reference Campbell and Smith2003), have a more familiar classification that differentiates bibliotherapeutic resources into those put to clinical use for treating specific mental health issues and those used for informational/supportive purposes.
In 1904, a librarian at McLean Hospital in Massachusetts developed a programme combining psychiatry and library science and the Menninger clinic in Kansas not only used bibliotherapy, but also employed a librarian with the title bibliotherapist (Tews Reference Tews1970). The ‘Reading Well Books on Prescription scheme’ is an English scheme that has the endorsement of the Royal Colleges of General Practitioners, Nursing, Psychiatry, the British Association for Behavioural/Cognitive Psychotherapies and of the Department of Health through its ‘Improving Access to Psychological Therapies Programme’. Work on its development commenced in the late 1990s, and is currently being funded by Arts Council England. The scheme follows NICE guidelines, and uses 30 books that are endorsed by health stakeholders as having evidenced cognitive behaviour therapy (CBT) benefits.
In March 2007, the North Inner City Partnership in Primary Care (Dublin), in collaboration with Dublin City Public Libraries, piloted the first book prescription scheme in Ireland called ‘Books Can Help’, led by Elaine Martin, HSE senior psychologist. In Ireland, bibliotherapy enjoys positive media coverage, with the launch of the University College Dublin book prescription scheme on 21 January 2008, with over 182 books. The medical and counselling staff members prescribe these books to students who attend the students’ health centre as part of their treatment and they have book lists and prescription pads for this purpose. The ‘Books Can Help’ scheme issued over 2500 books in the first year so extended to a national project involving the HSE, ICGP and National Library Council entitled ‘The Power of Words’ (launched February 2009).
Although most schemes occur in primary care in Ireland, the didactic form of bibliotherapy is however an effective therapeutic tool for mental health professionals in secondary care, because there is a good evidence base supporting its effectiveness in the treatment of depression (Gregory et al. Reference Gregory, Schwer Canning, Lee and Wise2004; Morgan & Jorm Reference Morgan and Jorm2008), insomnia (Van Straten & Cuijpers Reference Van Straten and Cuijpers2009), bulimia nervosa and binge eating disorder (Sysko & Walsh Reference Sysko and Walsh2008). Initially, it was thought to be effective for only mild/moderate illness with guidance from professionals, however, recent research shows greater effect sizes with more severe disease and effectiveness did not vary with type of support; rather effectiveness may vary in a case specific way with different types of support when used for mental health conditions (Frude 2005).
Although bibliotherapy has proved popular among social workers, psychologists, psychotherapists and other health care professionals; critiques of bibliotherapy have also taken many approaches. Some have concerns that bibliotherapy can become an inadequate substitute for formal therapy and aftercare (Silverberg Reference Silverberg2003). Others believe that attempts to box bibliotherapy into an empirical and positivist world view risks a loss of focus on the relationship between the text and the reader. As a result only manualised forms of bibliotherapy that are possibly more compatible with quantitative research have been embraced by clinicians (Dysart-Gale Reference Dysart-Gale2008).
Methods
The online survey program SurveyMonkey was used to deliver a survey. First, trainees were asked whether or not they recommended self-help books. Second, they were asked to respond to three statements related to bibliotherapy. These statements were:
∙ I would be comfortable recommending books to a patient as a therapeutic aid,
∙ self-help books can only ever be a poor substitute for psychotherapy or counselling, and
∙ self-help books can cause more harm than good.
Each item was rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).
Third, respondents were asked to name which specific texts they recommended to patients. Finally, they were asked about their awareness of book prescription schemes.
This survey was then sent to three Senior Registrars known to the authors to assess face validity and clarity of structure and design. The feedback from this process indicated that the questionnaire was appropriately structured and possessed face validity. An email list that is used to distribute information to Senior Registrars in psychiatry and those in posts recognised for higher training accreditation was used to disseminate the survey. This survey was done before Lance Armstrong confessed to using performance-enhancing drugs.
This list contained the email addresses of 82 individuals, who are sent emails regarding teaching sessions and other notices. There were 34 responses, providing a response rate of 41.5%. The majority are Senior Registrars, enrolled on the Irish Psychiatric Training Committee’s Higher Training in Psychiatry scheme. Also on this list are Research Registrars whose posts are recognised for higher training, and also some Consultants who have recently been on the Higher Training Scheme. The age range on the scheme is from ~20–40. An email was sent to this list with a link to the survey, a brief explanation of the purpose of the study, and an indication that completing the survey should take no more than 5 minutes.
Participants
The majority 29 (85.3%) of respondents identified themselves as Senior Registrars, two as Research Registrars, one as a Consultant Psychiatrist and one did not respond to this item. The Consultant Psychiatrist was recently appointed and was included on the email list, so this individual’s results are included.
Attitudes and practices
Most 22 (64.7%) respondents said that they recommend/prescribe books to their patients, with 12 (35.3%) saying they did not. The majority 27 (79.4%) strongly agreed or agreed that they were comfortable recommending books, with none strongly disagreeing and four (11.8%) disagreeing. Over half 20 (58.8%) of respondents strongly disagreed or disagreed that self-help books could only be a poor substitute for psychotherapy or counselling, with none strongly agreeing and two (5.9%) agreeing. Many 19 (55.9%) disagreed or strongly disagreed that self-help books could do more harm than good, with eight (23.5%) agreeing or strongly agreeing. Finally, respondents were asked to state their awareness of prescribe-a-book schemes. Four (11.8%) respondents reported awareness, with 30 (88.2%) unaware of any such schemes.
Recommended bibliotherapy titles
Four respondents who answered about individual texts gave a single reply, nine gave two, six gave three and two gave four. Four of these replies were not specific texts but along the lines of ‘lots of the “Overcoming” series’ or ‘information on weight management and side effects’. Twenty-five individual texts were given. Of these, Mind Over Mood (Greenberger & Padesky Reference Greenberger and Padesky1995) was by far the most frequent, featuring 14 times. Five other individual titles were mentioned twice – Overcoming Anxiety, Overcoming Depression, Overcoming Low Self Esteem, Mindfulness-Based Cognitive Behaviour Therapy and Understanding and Managing Depression. Overall the Overcoming series, if considered as a single title, was mentioned eight times (including the respondent who mentioned lots of the Overcoming series).
Most of these texts represent the didactic rather than imaginative approach. The four (arguable) exceptions were, An Unquiet Mind (Jamison Reference Jamison1995), It’s Not About the Bike (Armstrong & Jenkins Reference Armstrong and Jenkins2001), The Illness Narrative (Kleinman Reference Kleinman1989) and Man’s Search For Meaning (Frankl Reference Frankl1963). Of these, The Illness Narrative and Man’s Search for Meaning were written with a specifically therapeutic aim. An Unquiet Mind and It’s Not About the Bike were not, although both have been promoted as being of inspirational as well as informational. It’s Not About the Bike, a memoir by a cyclist and cancer survivor Lance Armstrong, was the least conventionally bibliotherapeutic work on the list. A respondent also mentioned the book, Easy Way to Stop Smoking (Carr Reference Carr2004), although this is not a book about a psychiatric illness directly.
Discussion
With 34 out of 82 recipients of emails on this list, responding, the response rate could be said to be low. This may mean that respondents were biased in favour of bibliotherapy, and may have been more likely to list specific texts. This email list is sent to psychiatric trainees who are predominantly clinicians, and whose access to and use of email may be variable.
The survey was intended to be brief, and to gauge attitudes overall. It could be argued that the didactic bias of the texts suggested may have been an artefact of the use of the term self-help book in the survey, rather than a reflection of general attitudes to bibliotherapy per se. Certainly more robust qualitative studies, using focus groups for instance, would be required to fully explore trainees’ attitudes to and use of bibliotherapy.
The low awareness of book prescription schemes may reflect the fact that these schemes have more buy-in within primary care services in Ireland and have not been disseminated to practitioners within the mental health services. This may reflect a tendency to view service users within the mental health services as requiring more intensive treatment and by extension possibly reflects a view that bibliotherapy is essentially a less effective therapeutic tool. It also points to a challenge for librarians and psychologists who have developed bibliotherapy programmes to engage with secondary and tertiary mental health services, as well as primary care.
Mind Over Mood and the Overcoming series are both based explicitly on CBT and were a favourite with these trainees. The CBT focus of these books reflects how this approach lends itself to workbook form. Characterised by a collaborative approach with the therapist, CBT approaches tend to involve much homework. CBT’s popularity within psychiatry has been frequently documented and critiqued by some (Gaudiano Reference Gaudiano2008). For its critics from the psychoanalytic world, CBT approaches simplify complex issues and impose a mechanistic, behaviourist view of the human psyche.
In conclusion, senior trainees in psychiatry have generally positive attitudes to bibliotherapy. Certain texts are reported to be frequently recommended. The texts listed overall reflect a tendency towards didactic texts and cognitive behavioural approaches, with Padesky and Greenberg’s Mind Over Mood especially popular. There was low awareness of specific book prescription schemes among respondents. It is interesting that the two most popular choices among Irish trainee psychiatrists also feature in the top 10 and top 50 books listed in popular practitioner surveys on evidenced-based resources for use in book prescription schemes (Norcross et al. Reference Norcross, Santrock, Campbell, Smith, Sommer and Zuckerman2000; Forman et al. Reference Forman, Gaudiano, Redding and Herbert2008).
This study has limitations as outlined above and is intended to act as a stimulus and a starting point for further study. There is great potential for bibliotherapy as an important aspect of patient management and the library profession are already exploring this (Horne Reference Horne1975). Non-mental health clinicians have also found it useful in hospital settings (McMillen & Pehrsson Reference McMillen and Pehrsson2004). However, the possible role of psychiatrists in bibliotherapy is one that requires further elucidation. One way of disseminating this information to psychiatrists would be through including bibliotherapy as a module in their post-graduate training curriculum. The apparent reluctance to recommend more imaginative/informational and less structured texts could also be explored. Further research can also be done in Ireland to investigate whether self-help resources (CBT or other types) with telephone or minimal support are as effective for eating disorders and other mental health conditions as they are for the treatment of depression.
Acknowledgements
Sincere thanks goes to the anonymous peer reviewers who critiqued this paper and made it better in the process. Our appreciation also goes to everyone who contributed to this study and the psychiatrists who completed the online survey.
Conflicts of Interest
None.
