I remember reading in an interview with John Murtagh, the doyen of General Practice in Australia, that he used to keep a list of all the masquerades up on the wall behind his patient’s head, so that he would not miss an important diagnosis. Once he had satisfied himself that he had excluded these and any other organic causes of the symptoms, he was free to sit with the patient and help them realise what it was that truly ailed them.
I do think that certain sorts of doctors get certain sorts of presentations. I have always been the sort who attracts psychosocial problems. That used to stress me, but now I’m trying to see it as my superpower. Indeed, I’m attempting to “lean in” to this superpower by opening a new private practice, called Byron Bibliotherapy.
History of Bibliotherapy in Hospitals and Institutions
Bibliotherapy is a term that comes from the Ancient Greek biblio, meaning book, and therapy, meaning healing. Aristotle compared reading to a sort of healing for the soul. In times past, small libraries have adjoined hospitals and their books have been read to or by patients, in an attempt to touch their souls while they were physically healing. In the 19th Century, bibliotherapy was seen as an integral part of inpatient rehabilitation, and was termed “moral therapy.”
By the early 20th Century, advances in medical diagnosis meant “moral therapy” declined. After the Second World War, the rise of medical education saw the hospital and asylum library take on more of a curatorial and educative role for medical staff, rather than therapeutic for patients.
Some hospital librarians remained passionate about their therapeutic roles, running story hours and book clubs. One such librarian was Sadie Peterson Delaney, who worked with African American veterans in a United States repatriation hospital after both World Wars.
Since then, bibliotherapy has been used as a therapeutic model with various population groups, including at-risk youth and prisoners. For such marginalised groups, studies have shown a clear benefit for treating depression. Group members were introduced to stories from literary greats, such as Dickens and Shakespeare. The readers became part of an “interpretive community” that dealt with more complex issues. This allowed more discussion, insight and awareness than the usual problem-solving techniques. Researchers and participants reported that among this group of depressed patients, calming of agitation and mental anxiety was frequently observed (Billington, 2011, cited in Yontz-Orlando).
Bibliotherapy in the Community
Bibliotherapy is big in the UK and there have been a lot of studies looking at its efficacy. This is likely in the context of the public funding model of the NHS and its emphasis on Evidence-Based Practice. It has been taken up in the UK with the enthusiasm expected of a cost-effective form of therapy that can be offered during the waiting period for more traditional psychotherapy.
Various programs have demonstrated significant improvement in mental health outcomes, including the Read Yourself Well project delivered via the public library in East Ayrshire, Scotland. This treatment plan was directed towards self-referrals and welfare agencies. One hundred and fourteen people participated in the study, which consisted of a pre-intervention and 3-month post-intervention written assessment (MacDonald, Vallance, & McGrath, 2013).
The first such program was Books on Prescription in 2003. It offered a list of cognitive-behavior therapy (CBT) readings. It benefited good readers and highly motivated patients, however suffered from a limited list of resources and no supportive follow-up (Brewster, Sen, & Cox, 2012).
Indeed, bibliotherapy is enough of a hot topic in the UK to warrant its own conference in September 2018. Titled “The Book as Cure: Bibliotherapy and Literary Caregiving, from the First World War to the Present,” it will be hosted by The Open University and the Institute of English Studies, University of London. The conference aims to look at the legacy of wartime bibliotherapy through an “interdisciplinary dialogue about the curative power of reading during and after the war.” Some questions they hope to address include: “In what ways does the legacy of First World War bibliotherapy remain active in contemporary policy-making in the charity sector, and in work with veterans and settled refugees?”
Bibliotherapy in Schools
Good teacher-librarians and teachers have probably always tried to reach at-risk children by offering them support, referral to a counsellor or perhaps a resource that might help them. Many librarians have lists of books that might resonate with certain children. They often present these in a non-threatening manner on leaflets or bookmarks around the library.
Bibliotherapy in Australia
The School of Life in Melbourne and Sydney offers bibliotherapy sessions in-person and via Skype.
The Central West Library service In Orange, NSW have partnered with the Centre for Rural and Remote Mental Health to offer a Books on Prescription service.
The Handbook of Non-Drug Intervention (HANDI) Project Team has published “Bibliotherapy for Depression” in the Australian Family Physician. It is indicated for patients with mild to moderate depression, with a reading age above 12 and a positive attitude towards self-help. The books are mainly self-help and CBT.
As mentioned above, I started Byron Bibliotherapy in late 2017 in an attempt to “lean in” to my calling in mental health. I’ve always spent a large proportion of my day dealing with anxiety and depression, which I think is quite common for female GPs. Sometimes I have suggested specific novels to my patients, and they have often reported that they have been so helpful to them. So Byron Bibliotherapy was born to help those people, and to combine my passion for books with my medical practice.
I’m not too fazed by the lack of evidence about bibliotherapy. I’m definitely a proponent of evidence-based medicine. However, I do recognise that humans are funny creatures. We often act illogically and in direct opposition to what is best for us. As GPs we’re all aware of this, in the context of non-adherence with treatment regimens. As humans, we’re all aware of this in our difficulty losing the last 3kg, or our struggles with procrastination or salary-sacrificing to superannuation.
There is currently not much data on the effectiveness of bibliotherapy. There is one study on long-term follow-up of cognitive bibliotherapy for depression (Smith et al). However, there is also a dearth of data for much best practice in medicine. I take heart from Murtagh himself saying that, “For the everyday nitty-gritty problems of general practice, recommended treatments include those that have worked effectively for myself and my colleagues” (Murtagh, xv). In the future, I would like to be involved with research into bibliotherapy as an intervention.
In terms of matching patients up with books, I am an avid but slow reader. Like most medical graduates though, I am adept at recognising what I don’t know and when to call for help. Instead of calling a MET call, in bibliotherapy I call for help from specialist professionals. Booksellers, librarians, writers and publishers are all a wealth of information. I also rely on specialist amateurs: keen reader friends and fellow book club members.
I am aware of the potential negative aspects of bibliotherapy for certain patients. Like all psychotherapies, there needs to be a therapeutic relationship first and foremost. It is contraindicated for some patients with severe mental health issues such as psychosis. In these situations, I feel my general practice background and further mental health training have prepared me to recognise when and how to refer to more suitable care.
There is also the issue that is brought up very eloquently in this article in The Horn Book. Teacher Librarian, Maeve Visser Knoth, discusses all the times suggesting a book would be inappropriate. For example, it might be too much soon after your mother is diagnosed with cancer. However, inoculating your children through reading about difficult issues before they happen, can be helpful by enabling them to rehearse a difficult situation.
I like this idea a lot. Just as I’m committed to vaccination in an Anti-Vax region, I’m happy to think the articles on my website might suggest enough emotionally complex books to help inoculate people against what life throws at them.
I passionately believe in the benefits of bibliotherapy as described by Alex (1993, cited in Maich and Kean): awareness that others have faced similar problems; knowledge that alternative solutions to problems exist; development of a freedom to talk about problems; growth of problem solving skills; further development of a positive self concept; relief of emotional or mental stress; development of honesty in self image; growth of interests beyond just the self; and fostering of a better understanding of human behaviour.
If you have a patient or loved one who is at a crossroads, who may be reluctant to see a psychologist, or even a “worried well” patient who is suffering, I’d love to see them! Gift certificates are also available.
- a pre-consultation questionnaire
- a 45-minute individual consultation
- a Novel Prescription, emailed one week later.
In-person consultations are $220. They may be eligible for a Medicare rebate of $132.75 (Item 2725) under a Mental Health Care Plan.
Video-consultations are available and cost $180. There is no Medicare rebate available for video-consultations. Follow-up consultations may be arranged on a case-by-case basis. (Costs are based on a consulting rate of $70/hr, which is extremely good value for a medical practitioner.)
A Hero’s Journey:
For those at a transition and interested in a more intense 3-month program, structured around narrative theory.
MacDonald, J. J., Vallance, D. D., & McGrath, M. M. (2013). An evaluation of a collaborative bibliotherapy scheme delivered via a library service. Journal of Psychiatric & Mental Health Nursing, 20(10), 857-865
Maich, K. & Kean, S. (2004) Read Two Books and Write Me in the Morning: Bibliotherapy for social emotional intervention in the inclusive classroom. TEACHING Exceptional Children Plus, 1(2) Article 5. http://escholarship.bc.edu/education/tecplus/vol1/iss2/5
Murtagh, J. (2007). John Murtagh’s General Practice (4th ed). McGraw-Hill, Sydney.
Smith, N.M., Floyd, M.R., Jamison, C.S. and Scogin, F. (1997). Three-Year Follow-Up of Bibliotherapy for Depression. Journal of Consulting and Clinical Psychology, 65(2), 324-327.
Robertson, R., Wray, S. J., Maxwell, M., & Pratt, R. J. (2008). The Introduction of a Healthy Reading Scheme for People with Mental Health Problems: Usage and Experiences of Health Professionals and Library Staff. Mental Health in Family Medicine, 5(4), 219-228.
Yontz-Orlando, J. (2017) Bibliotherapy for Mental Health. International Research in Higher Education Vol. 2, No. 2; 2017. doi:10.5430/irhe.v2n2p67
Dr Zewlan Moor spoke at the NoRDocs Unconference
in Lismore on 30 June, 2018