# Motivation and emotion/Book/2024/Bibliotherapy and emotion

* Multimedia presentation (3 min)

## Overview

* Meet Alex ...
* Alex has recently moved abroad to attend their dream university. While they are grateful for this opportunity and like their new city, they haven't yet made any new friends. Alone in a new place and without social ties, Alex often feels homesick and detached from their surroundings (see Figure 1). They are suddenly uncertain of their identity and unsure how to navigate these new feelings. Although they desire to reach out to someone, they're unsure how to express these emotions.
* After learning about what bibliotherapy is and how it works, we will examine how the therapeutic treatment can be applied to help Alex.
"That is part of the beauty of all literature. You discover that your longings are universal longings, that you're not lonely and isolated from anyone. You belong." -- F. Scott Fitzgerald (see Figure 2; as cited in Bausells, 2016).
Mental health challenges are a growing concern across [what?] populations, with studies finding particularly high levels of psychological distress amongst university students (Baik et al., 2019). A variety of factors, such as academic pressure and life transitions, can severely impact students' physical, cognitive, emotional, and interpersonal wellbeing. In response to this, mental health practitioners have explored a range of cost-effective interventions to support emotional wellbeing. One such example is bibliotherapy.
Emotional wellbeing is an umbrella term for psychological concepts including feeling satisfied with life, having a sense of purpose, and experiencing positive emotions (Feller et al., 2018). Research has demonstrated that emotional wellbeing may causally contribute to healthy ageing and longevity (Cross et al., 2018; Kushlev et al., 2020; Ngamaba et al., 2017). Given its importance, supporting emotional wellbeing across populations is vital for both physical and mental health.
Bibliotherapy, the applied use of literature as a therapeutic tool, has been shown to improve the emotional states of readers and foster empathy (Peterkin & Grewal, 2018); these are both vital to enabling understanding of, and connection with, others. It can additionally encourage self-reflection, by offering readers new perspectives on their challenges and providing models of resilience and growth. Given the wide-reaching importance of emotional wellbeing, bibliotherapy represents an accessible avenue for individuals looking to enhance their emotional health. It is a powerful tool for both clinical and self-directed mental health care.
* Focus questions
* What are the mechanisms of action that allow reading to improve emotional wellbeing?
* In what situations is bibliotherapy most effective?
* What are the limitations to the practical application of bibliotherapy?

## Bibliotherapy: What it is and why it works

The term 'bibliotherapy' is derived from the Greek biblion, meaning 'book,' and oepatteid, meaning 'healing.' At present, there is no universally accepted definition of bibliotherapy, which has also been referred to as 'reading therapy' or 'library therapy.' Both definitions and delivery frameworks can vary widely (Redman et al., 2024; Peterkin & Grewal, 2018[Use alphabetical order]).
At its core, bibliotherapy involves the use of books or other media to resolve personal challenges (Canty, 2017). More precisely, it is an active self-help, non-pharmacological intervention that incorporates cognitive behavioural therapy (CBT) techniques; it aims to help individuals manage negative emotions and implement coping strategies in daily life (Gualano et al., 2017)[grammar?].
Bibliotherapy is far from a new phenomenon. Its origins trace back to the Ancient Greeks, who believed that fictional tragedies could evoke catharsis in audiences, and the Romans, who prescribed the ill with specific speeches to improve mental health (Rubin, 1978). The present expression of bibliotherapy stems from Humanists who argued for the humane treatment of mentally ill patients. Such treatment specifically included the necessity of reading to patients and ensuring that they had books readily available to them (Canty, 2017). The next significant boost for bibliotherapy arrived during World War I, when librarians and the Red Cross installed libraries in army hospitals (Canty, 2017; see Figure 3). The term itself was coined in 1916, and has continued development since. Today, a variety of professionals from nurses to librarians and social workers practice bibliotherapy, offering both individual and group-based interventions.

### Mechanisms of action

According to Canty (2017), bibliotherapy follows three main stages:
* Identification of involvement: Readers connect with the material. In the case of a fictional book, this could include a character who is facing similar challenges to themselves. In the case of nonfiction self-help books, the identification may be with the author, if they self-disclose their own struggles, or with the examples provided in the text. This identification allows readers to see parallels between their own struggles and those in the text.
* Catharsis: Described as a 'lightbulb' moment, and sought also by the Ancient Greeks from their theatre audiences, this stage is characterised by a release of, and relief from, strong or repressed emotions.
* Insight: otherwise described as the action stage, this final stage is where readers develop practical strategies based on what they have learned from the text. These strategies are then implemented into their everyday lives.
Though this process is widely accepted, why does it work? This is the question Redman et al. (2024) posed in their study. The researchers conducted a systematic review and found different mechanisms of action that drive bibliotherapy, depending on the type of text used. They suggested that self-help books work because the therapeutic model they are following, CBT, works. When reading, cognitive processes such as reframing assist readers in developing a deeper understanding of unhelpful cognitions and, as such, make way for more realistic thoughts and actions. Redman et al. (2024) highlighted that some researchers believe similar mechanisms of action for creative texts—that is, experiencing stories through fiction, poetry, and film could act on these same CBT pathways. However, empirical research has shown that fiction is processed differently from non-fiction and, thus, differences in brain activation occur. Altmann et al. (2014) proposed that fiction can improve our ability to understand different perspectives as a result of the mechanism through which our brains process and comprehend narratives. This is theorised to be a result of the transportation effect, which refers to the way stories immerse readers in fictional worlds, helping them see things from new perspectives and leading to real-world changes in their thoughts and behaviours. Factors that enhance the transportation effect include:
* Similarities, both demographic and between the reader's and character's lives, and
* Sharing the experience with others in the real world (for example, through group bibliotherapy). This can allow the reader to form genuine connections and a sense of community, which are both considered essential elements for mental health recovery.
* Think Outside the Box Flat Icon GIF Animation
* Alex's experience with bibliotherapy
* Alex is referred to a bibliotherapy group, where they begin reading The Late Mattia Pascal [link?] (Pirandello, 2009) They quickly relate to the protagonist's feelings of disconnection from the self and society. Facilitated by group discussions, Alex is able to draw parallels between their own struggles and those of the main character, which helps them articulate the feelings that had previously felt inexpressible. This process fosters self-awareness and emotional release, allowing Alex to begin re-establishing their sense of identity.
* Through the narrative, Alex is able to engage with their complex emotions and begin to re-establish their sense of self and identity.
To maximise the benefits of bibliotherapy, there are additionally four significant components that should be included in the group-based format. Billington et al. (2010) identified these components through their study, which included two weekly bibliotherapy groups composed of adults diagnosed with depression. The first three components were found to be essential for the success of a group-based bibliotherapy intervention, while the fourth was influential. They are as follows:
* Rich literary material: Both fiction and poetry were found to help participants access new and forgotten ways of thinking and feeling.
* A skilled facilitator: The group leader has a crucial role in selecting accessible literature and guiding meaningful discussions. The facilitator's social awareness and communication skills were additionally found to be essential in fostering trust within the group.
* Group support: A sense of community is built through the shared reading model and group discussions, which enables members to connect and share their personal ideas, feelings, and opinions. This enhances the sense of collective identity.
* Environment: While not essential, the setting of the intervention can influence atmosphere and group dynamics. For example, the researchers found that a mental health drop-in centre encouraged more open engagement than a clinical setting.
** Note: the combined effects of the first three components eventually overcame the influence of the environment. For this reason, the environmental component was not deemed as essential to the success of a group-based bibliotherapy intervention.
* Think Outside the Box Flat Icon GIF Animation
* Alex's experience with bibliotherapy
* Take a moment and consider: how do you think Alex's journey would have differed if the criteria listed above had not been met during their bibliotherapy intervention?

### Types of bibliotherapy

With no universal agreement on what constitutes bibliotherapy, it should be unsurprising that its implementation can vary widely. Although the differing types of bibliotherapy have many different names, they broadly fall into two categories:
* Interactive bibliotherapy: This approach involves an active therapeutic relationship. It centres on exploring the client's response to the reading material and relies on CBT as its main therapeutic model (Peterkin & Grewal, 2018; Canty, 2017).
* Self-guided bibliotherapy: A low-cost alternative to therapist-led interventions. This approach involves independent reading. A therapist or another professional may suggest specific reading materials for independent exploration, often recommending self-help books that guide the reader through CBT techniques (Peterkin & Grewal, 2018; Redman et al., 2024). Although self-guided bibliotherapy often relies on instructional, non-fiction literature, it is important to keep in mind that creative texts are also used to facilitate the therapy.
Both of these options have empirical evidence [Provide more detail] to support their use and selection should be based primarily on individual needs.
Test yourself
Which therapeutic model is commonly applied in bibliotherapy?
Humanistic therapy.
Cognitive behavioural therapy.
Psychoanalysis.
Gestalt therapy. :

## Applications of bibliotherapy for emotional wellbeing

Bibliotherapy has proven to be a valuable tool for improving emotional wellbeing across a wide range of emotional challenges, with research repeatedly supporting its efficacy, especially for individuals with mild forms of depression (Gualano et al., 2017; Billington et al., 2010). This population, in particular, may not be ready to engage in more traditional therapies, and forms of self-guided bibliotherapy offer accessible and affordable alternatives with minimal therapist involvement and less time commitment. When delivered in a self-guided format, bibliotherapy also provides a non-stigmatising option. Notably, research shows that the positive effects gained from bibliotherapy are long-lasting, helping to reduce depressive symptoms throughout extended follow-up observation periods in adult populations (Gualano et al., 2017).
For those individuals willing and able to engage in a more structured, interactive process, Billington et al. (2010) found group-based bibliotherapy to have positive outcomes. Although the absence of a control group in their study limits the generalisability of their results, participants consistently valued reading groups for their ability to stimulate meaningful activity, foster social connection, and provide a means of relaxation. The intervention improved their emotional wellbeing by promoting self-awareness, enabling individuals to articulate their struggles, and alleviating social isolation.
Although most studies focus on the adult population, bibliotherapy has also proven to be effective in populations of young children, especially in relation to reducing anxiety symptoms. The historical practice of reading fairy tales and stories to children to sooth them (see Figure 4) is supported by empirical evidence. A study by Lewis et al. (2015) found that the use of bibliotherapy significantly reduced nighttime anxiety and associated avoidance behaviours in children. Both children and their parents reported these reductions in symptoms, and nearly all participants exhibited clinically significant behavioural improvements.
Bibliotherapy is also being explored in increasingly novel ways. For example, a review by Peterkin and Grewal (2018) found the therapy to be beneficial to patients coping with cancer diagnoses. Cancer patients would have difficulty reading by themselves because the frontal lobe, responsible for attention and active when interpreting visual information during reading, is most affected by cancer treatment (Wells et al., 2023). However, a read-aloud format of bibliotherapy offers an adaptable alternative for this population. Wells et al. (2023) found that the use of creative texts, such as poetry, led to significantly reduced anger and anxiety in patients. Moreover, an intervention utilising self-help books contributed to improvements in empowerment, coping skills, quality of life, emotional support, as well as reductions in distress, depression, and anxiety (Wells et al., 2023). The study suggested that bibliotherapy programs can benefit patients across outpatient, inpatient, and palliative care settings.
The empirical evidence consistently demonstrates that reading has the ability to enhance emotional wellbeing across diverse contexts and populations. Although each study presented above utilises different types of bibliotherapy, the core concept of using reading to promote mental health remains well-supported.

## Limitations of bibliotherapy

Despite its demonstrated benefits, it is important to note the challenges that bibliotherapy presents. One significant issue relates to research methodologies. Redman et al. (2024) highlighted the lack of attention that is paid to the actual content of texts used in interventions. Most studies focus solely on quantifiable aspects of the texts that they select, such as page count and reading level, without considering factors like linguistic style or the specific therapeutic interventions contained within self-help books. This creates difficulties in evaluating how such elements contribute to the effectiveness of an intervention. Additionally, there is a large disconnect between existing bibliotherapy theory, which primarily concerns itself with individual reading, and empirical research, which has mostly focused on group-based interventions (Troscianko et al., 2022).
Peterkin & Grewal (2018) identified further methodological issues across studies, including small sample sizes and heterogeneity in populations, outcomes, and clinical components of the therapy itself. These factors impede comparisons between studies and limit generalisability. Furthermore, in line with the critique from Redman et al. (2024), Peterkin and Grewal (2018) found a lack of clear strategies for selecting appropriate texts. The selection of inappropriate or triggering material has the potential to evoke mental distress or traumatic memories in vulnerable participants. If individuals are not yet ready to confront such emotions and memories, the inappropriate selection of literature could have significant negative effects on emotional wellbeing, and potentially deter participants from seeking further help.
Practical limitations of bibliotherapy must also be considered. Gualano et al. (2017) highlighted a common critique of bibliotherapy, which is its reliance on reading and retention skills. This can pose challenges for individuals with limited reading abilities or education. However, studies have shown that being read to can offer similar emotional benefits as reading independently (Wells et al., 2023; Lewis et al., 2015). Therefore, the intervention can be adapted by involving caregivers, therapists, or community helpers to support participants through read-aloud sessions, ensuring comprehension and engagement with the material.
Although bibliotherapy offers numerous demonstrated benefits, the therapeutic tool is still in development. The current challenges, both methodological and practical, call for further empirical research to refine the therapy and address its limitations.
Test yourself
What significant methodological issue did Peterkin et al. (2018) identify in bibliotherapy studies?
Inconsistent usage of CBT.
Over-reliance on qualitative data.
Small sample sizes and heterogeneity in populations. :

## Conclusion

The act of reading literature has a profound impact on emotional wellbeing, as evidenced by psychological theory and research. Broadly, bibliotherapy operates through the stages of identification, catharsis, and insight, providing individuals with a structure to process emotions. Fiction fosters emotional connection and empathy, helping readers gain new perspectives on their personal challenges, while self-help books leverage CBT techniques to offer practical solutions.
Bibliotherapy is especially beneficial for individuals facing mild mental health challenges such as mild depression or anxiety, offering a non-pharmacological option. It is additionally advantageous to those who lack the time or economic resources to attend traditional therapy. However, the therapy itself is not without its limitations. These include a reliance on reading ability, the potential for triggering negative emotions, and the methodological weaknesses found in the empirical research.
Despite challenges, bibliotherapy remains an accessible, low-cost intervention that has the potential to improve an individual's emotional wellbeing. It is highly adaptable to the unique needs of individuals and can be beneficial across diverse populations. While its use should be considered in reference to its limitations, bibliotherapy represents a promising tool for improving emotional wellbeing.