What is Bibliotherapy and Why does it Matter to Health and Social Care Practitioners?
by Ann Wales
“Knowledge is limited. Imagination encircles the world.” Einstein (1879-1955)
This brief overview of bibliotherapy and its benefits for health and social care is based on experience since 2011 in delivering the Knowledge into Action Strategy for Scotland’s health and social care (1,2). The inspiration behind this strategy is that “the transfer of knowledge is care” (3). In other words, high quality of care depends on humanistic sharing of knowledge among partners in care – particularly between practitioners and service users and carers. This transfer of knowledge forms the basis for practitioners and service users translating that knowledge into decisions and actions that improve health and wellbeing. As such, Knowledge into Action recognises the therapeutic value of accessing, sharing and reflecting on information and knowledge in all its forms – from self-management material to creative literature.
The transfer of knowledge through bibliotherapy aligns with the holistic approach to care described in the Quality Strategy (4), 2020 Vision (5), public services reform and integration (6). The House of Care model (7) promoted by the person-centred care programme provides an underpinning framework for these strategic themes, illustrating how sharing of knowledge can transform the practitioner-patient relationship, strengthen self-management, and realise the potential of community assets to help people to take more charge of their health and wellbeing.
Definition and scope of bibliotherapy
Broadly defined, bibliotherapy is a spectrum of approaches that use an individual’s relationship to the content of written and spoken words as therapy. All forms of bibliotherapy are based on the fundamental idea that reading and storytelling are healing experiences, The individual’s interaction with the words can lead to personal assessment and reflection, validation of individual experience, deeper understanding of the personal meaning of health and illness, self-knowledge, and growth, which increase capacity for self-determination and behavioural change.
Bibliotherapy covers a continuum that ranges from simple reading of self-management information, based on cognitive behavioural therapy principles. to person-centred reading of poetry and fiction, and storytelling, accompanied by discussion and support. Depending on context and need, this support may be provided from a bibliotherapist without clinical training, or from a health or social care practitioner. Where support is part of bibliotherapy, the literature becomes an enabler that helps to transmit ideas, build empathy and strengthen the therapeutic relationship.
Evidence base for bibliotherapy
There is a strong and growing evidence base for the effectiveness of the various forms of bibliotherapy and for their cost-effectiveness for mild to moderate mental health issues, compared with costly psychiatric interventions and medicines.. The National Institute for Health and Care Excellence (NICE) guidelines recommend use of self-management information based on cognitive behavioural therapy principles for a wide range of healthcare issues:
- Common mental health disorders, including commissioning of stepped care.(8,9)
- Depression. (10)
- Generalised anxiety disorder and panic disorder in adults, and social anxiety disorder (11). This includes reference to Books on Prescription as an accredited self-help resource.
- Eating disorders (12)
- Chronic fatigue syndrome (13)
- Obsessive compulsive disorder and body dysmorphic disorder (14)
Similarly the SIGN guidelines for depression (15) recommend use of self-management information, and bibliotherapy can contribute to the HEAT target of reducing prescription for depression.
Considering the broader spectrum of bibliotherapy, Marrs’ meta-analysis of seventy-nine bibliotherapy studies (16) showed a moderate but significant overall benefit on a range of outcomes including physiological measures, observed and self-reported behaviour and academic achievement. Anxiety-related conditions such as assertion, depression, anxiety and sexual dysfunction appeared more likely to improve as a result of bibliotherapy, compared with conditions related to need for immediate gratification – e.g. weight loss, studying problems and impulse control. Fanner and Urquhart (17) reviewed the evidence for library services supporting the rehabilitation needs of mental health service users through bibliotherapy . They found that the evidence strongly suggests that library-based interventions and the provision of information could be beneficial for service users and economical for the health service in assisting treatment of a range of conditions. The NHS Evidence site identifies over 150 trials and reviews of bibliotherapy (18) and many qualitative studies show the impact of creative reading on mood and stress levels (19).
Examples of bibliotherapy in health and social care in Scotland.
The following are just a few examples of many bibliotherapy initiatives in NHS Boards, local authorities and voluntary agencies in Scotland which have delivered positive impact on people’s health and wellbeing.
A number of NHS Boards (e.g. NHS Lanarkshire, NHS Tayside) have developed partnerships between healthcare teams and public libraries to offer collections of “Books on Prescription” for mild to moderate mental health conditions. Books on Prescription schemes in NHSScotland and beyond have evaluated well for impact on self-management, efficiency and therapeutic effect. (20, 21)
Bibliotherapists offer self-management and creative bibliotherapy in a number of public library services in Scotland, working in collaboration with local general practices, local social welfare agencies and through self-referral. (e.g. the Read Yourself Well Scheme in East Ayrshire, and the Healthy Reading Initiative in Midlothian). Again, this type of service has been evaluated as delivering positive impact for people with mental health problems.
The Carnegie UK Trust (23) has highlighted the important contribution of public libraries in improving the health and wellbeing of individuals and communities. The Scottish Library and Information Council has an active strategy of strengthening this role, and has funded a number of initiatives to support people in finding and using health information for self-management through public library services (24). Health issues supported in this way include dementia, healthy eating, cancer and other long term conditions.
Under the auspices of Knowledge into Action, NHS Education for Scotland (NES) has supported a number of bibliotherapy activities – including awareness raising amongst NHS Scotland librarians and the commissioning of a range of bibliotherapy opportunities for patients and the public. In total, nine bibliotherapy programmes with a total of 67 participants were delivered and evaluated, including the LivingLifetotheFull self-management bibliotherapy programme (25).. All interventions delivered positive impact on increased awareness of, and attitudes to, their own health and well-being, and the majority of participants reported changes in behaviour or decisions about their own health and well-being (26,27).
Vision for the future of bibliotherapy in Scotland’s health and social care.
In summary, the evidence from research and from practical experience in Scotland shows the potential of bibliotherapy to contribute to the transformation of care described in the 2020 Vision. There are many examples of good practice and innovation in Scotland, but to date these have been developed in isolation in individual organisations, lacking coordination or coherence across the journey of care, and creating the risk of investing effort without delivering maximum impact.
The Scottish Library and Information Council and NHS Education for Scotland have now entered into a collaboration to develop a strategic approach to fulfil the promise of bibliotherapy. The emerging vision is of a national network of NHS, local authority and voluntary sector library and information services, collaborating with health and social care teams to deliver a comprehensive range of evidence-based bibliotherapy services in the community. This toolkit , sponsored jointly by NES and Lapidus Scotland, will contribute to delivering this vision, helping to put the transfer of knowledge at the heart of a new model of care, based on therapeutic relationships and valuing of the individual’s experience.
1) NHS Education for Scotland and Healthcare Improvement Scotland (2012) Getting Knowledge into Action to Improve Healthcare Quality: Report of Strategic Review and Recommendations. http://www.knowledge.scot.nhs.uk/media/CLT/ResourceUploads/4016980/20120805%20K2A%20short%20report%20for%20Board%20distribution%20v2%200.pdf
2) Scottish Government (2012) A Strategy and Action Plan for Embedding Knowledge in Practice in Scotland’s Social Services. http://www.scotland.gov.uk/Publications/2012/10/4809
3)Institute of Medicine (2001) Crossing the Quality Chasm: A New Health System for the 21st Century, Chapter 3: Formulating New Rules to Redesign and Improve Care.
4) Scottish Government (2010). The healthcare quality strategy for NHSScotland Available from: www.scotland.gov.uk/Resource/Doc/311667/0098354.pdf
5) Scottish Government (2011). Achieving sustainable quality in Scotland’s healthcare: a 2020 Vision. http://www.scotland.gov.uk/Topics/Health/Policy/2020-Vision/Strategic-Narrative
6) Scottish Government (2014) Public Bodies (Joint Working) (Scotland) Act. http://www.legislation.gov.uk/asp/2014/9/contents/enacted
7) The ALLIANCE (2014) Scotland’s House of Care. http://www.alliance-scotland.org.uk/what-we-do/projects/scotlands-house-of-care/
8) National Institute for Health and Care Excellence (2011). Common mental health disorders: Identification and pathways to care. http://www.nice.org.uk/guidance/cg123
9) National Institute for Health and Care Excellence (2011). Commissioning stepped care for people with common mental health disorders. http://www.nice.org.uk/guidance/cmg41
10) National Institute for Health and Care Excellence (2009). Depression in adults: The treatment and management of depression in adults. https://www.nice.org.uk/guidance/cg90
11) National Institute for Health and Care Excellence (2011). Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: Management in primary, secondary and community care. http://www.nice.org.uk/guidance/cg113
12) National Institute for Health and Care Excellence (2004). Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. http://www.nice.org.uk/guidance/cg9
13) National Institute for Health and Care Excellence (2007) Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy): Diagnosis and management of CFS/ME in adults and children. http://www.nice.org.uk/guidance/cg53
14) National Institute for Health and Care Excellence (2005). Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. http://www.nice.org.uk/guidance/cg031
15) Scottish Intercollegiate Guidelines Network (2010). Non-pharmaceutical Management of Depression. http://sign.ac.uk/guidelines/fulltext/114/index.html
16) Marrs R W. A meta‐analysis of bibliotherapy studies. American Journal of Community Psychology.1995;23(6):843‐870
17) Fanner, D. . Urquhart, C. Bibliotherapy for mental health service users Part 1: a systematic review. Health Information and Libraries Journal. 2008 Dec;25(4):237-52
18) National Institute for Health and Care Excellence NHS Evidence: Bibliotherapy https://www.evidence.nhs.uk/search?q=Bibliotherapy (Accessed December 2014)
19) Reading Agency. Reading Well Books on Prescription: Evidence Base. Creative Reading. http://readingagency.org.uk/adults/impact/research/reading-well-books-on-prescription-scheme-evidence-base.html (Accessed December 2014)
20) Reading Agency. Reading Well Books on Prescription: Evidence Base.Books on Prescription Model. http://readingagency.org.uk/adults/impact/research/reading-well-books-on-prescription-scheme-evidence-base.html (Accessed December 2014)
21) Henry, E. and Marley, L. (2004), Helping the public ‘Discover Health’ in their local library. Providing health information in public libraries: a partnership approach in Scotland. Health Information & Libraries Journal, 21: 27–32. http://onlinelibrary.wiley.com/doi/10.1111/j.1740-3324.2004.00504.x/full.
22) Macdonald J1, Vallance D, McGrath M. An evaluation of a collaborative bibliotherapy scheme delivered via a library service. Journal of Psychiatric and Mental Health Nursing 2013 Dec;20(10):857-65.
23) Carnegie UL Trust (2014). Speaking Volumes: the impact of public libraries on wellbeing http://www.carnegieuktrust.org.uk/changing-minds/knowledge—culture/the-future-of-libraries/speaking-volumes
24) Scottish Library and Information Council (2014). Public Library Improvement Fund 2013 Grants: Health & Wellbeing. http://www.cilips.org.uk/storage/SLIC_Show_and_Tell_CILIPS_2014.pdf
25) Living Life to the Full. http://www.llttf.com/
26) NHS Education for Scotland (2014). Summary of Bibliotherapy Projects 2013-14 http://www.knowledge.scot.nhs.uk/healthliteracy/resources-library/resource-detail.aspx?id=4053393
27) NHS Education for Scotland (2014). Report of Bibliotherapy Pilot Projects 2013-14 http://www.knowledge.scot.nhs.uk/healthliteracy/resources-library/resource-detail.aspx?id=4053395