Informatio
26(2), 2021, pp. 7-29
ISSN: 2301-1378
DOI: 10.35643/Info.26.2.1
Dossier temático: Biblioterapia
1 Manchester Metropolitan University, Research Associate, UK, School of Childhood, Youth and Education Studies, Brooks Building, Manchester, M15 6GX. Correo electrónico: s.mcnicol@mmu.ac.uk.
2 Lancaster Medical School, Senior Lecturer, UK, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT. Correo electrónico: e.brewster@lancaster.ac.uk.
This article discusses three contrasting models of bibliotherapy which have developed in the UK over the last two decades. Building on the earlier history of bibliotherapy, each of these models aim to provide access to selected texts which it is hoped will have a positive effect on a reader’s mental health. The most widespread schemes draw from medical and healthcare knowledge to provide self-help resources for diagnosed mental health conditions. Alongside this, there are schemes shaped by literary and educational experts that focus on facilitating access to fiction and poetry (often with an emphasis on «quality fiction»), usually through group reading. In addition, there is a third model which has, thus far, received less widespread recognition. Drawing on key notions from social care and community development, this model places greater emphasis on the participants in bibliotherapy than on the resources that are used. This «person-centred» model takes a more inclusive interpretation of what we mean by a bibliotherapy «text» and has the potential for the future development of UK bibliotherapy through widening the audiences who want to engage with, and can benefit from, bibliotherapy.
Keywords: BIBLIOTHERAPY; SELF-HELP; SHARED READING; PERSON-CENTRED.
Este artículo analiza tres modelos contrastantes de biblioterapia que se han desarrollado en el Reino Unido durante las últimas dos décadas. Basándose en la historia anterior de la biblioterapia, cada uno de estos modelos tiene como objetivo proporcionar acceso a textos seleccionados que se espera tengan un efecto positivo en la salud mental del lector. Los esquemas más extendidos se basan en el conocimiento médico y sanitario para proporcionar recursos de autoayuda para las enfermedades mentales diagnosticadas. Paralelamente, existen esquemas elaborados por expertos en literatura y educación que se enfocan en facilitar el acceso a la ficción y la poesía (a menudo con énfasis en la «ficción de calidad»), generalmente a través de la lectura en grupo. Además, hay un tercer modelo que, hasta ahora, no ha recibido un reconocimiento tan amplio. Basándose en nociones clave de la asistencia social y el desarrollo comunitario, este modelo pone más énfasis en los participantes en la biblioterapia que en los recursos que se utilizan. Este modelo «centrado en la persona» adopta una interpretación más inclusiva de lo que entendemos por «el texto» y tiene el potencial para el desarrollo de la biblioterapia en el Reino Unido en el futuro – ampliando las audiencias que desean participar y pueden beneficiarse.
Palabras clave: BIBLIOTERAPIA; AUTOAYUDA; LECTURA COMPARTIDA; CENTRADO EN LA PERSONA.
Este artigo analisa três modelos contrastantes da biblioterapia que foram desenvolvidos no Reino Unido nas últimas duas décadas. Com base na história anterior da biblioterapia, cada um desses modelos tem como objetivo proporcionar acesso a textos selecionados que se espera tenham um efeito positivo na saúde mental do leitor. Os esquemas mais difundidos baseiam-se no conhecimento médico e sanitário para proporcionar recursos de auto-ajuda para as doenças mentais diagnosticadas. Paralelamente existem esquemas elaborados por especialistas em literatura em educação que se concentram em facilitar o acesso á poesia (frequentemente com ênfase na “ficção da qualidade”) geralmente a traves da leitura em grupo. Além disso existe um terceiro modelo que, até á data , não foi tão amplamente reconhecido. Baseado em noções-chave de ajuda social e desenvolvimento comunitário, este modelo dá mais ênfase aos participantes na biblioterapia do que aos recursos utilizados. Este modelo “centrado na pessoa” adota uma interpretação mais inclusiva do que entendemos por “texto” e tem o potencial para o desenvolvimento da biblioterapia no Reino Unido no futuro – ampliando os públicos alvos que querem participar e podem beneficiar.
Palavras-chave: BIBLIOTERAPIA; AUTO-AJUDA; LEITURA ARTILHADA; CENTRADO NA PESSOA.
| Fecha de recibido: | 31/05/2021 |
| Fecha de aceptado: | 07/09/2021 |
Bibliotherapy is complex and constantly developing as it draws on multiple disciplines (medicine and healthcare; psychology and psychiatry; information studies; literary studies; education; and social and community work) and has adapted in response to changes in the ways in which we view health and wellbeing as a society over time. This complexity is reflected in the historical development of bibliotherapy in the UK. Over the last two decades, three contrasting models of bibliotherapy have developed. These each aim to provide access to selected texts which, it is hoped, will have a positive effect on mental health. The most widespread schemes have focused on self-help resources for diagnosed mental health conditions. The development of these schemes draws most obviously on knowledge from the medical and healthcare professions. Alongside this, there has also been considerable interest in facilitating access to selected fiction and poetry (often with an emphasis on «quality fiction»), with a similar aim of improving mental health and well-being, usually through group reading. The approach taken by such schemes is shaped by literary and educational studies. Whilst both these approaches have spread nationally in the UK, and indeed internationally, a third model has, thus far, been more regionally based and so has, perhaps, received less widespread recognition. Drawing on key notions from social care and community development, this model places greater emphasis on the participants in bibliotherapy than on the resources that are used.
It is important to remember that these recent incarnations of bibliotherapy draw on a long, varied and international history. In the first part of this article, we therefore briefly outline the early development of bibliotherapy in order to place its more recent history in context. We then describe the growth of self-help bibliotherapy in the UK, in particular the Books on Prescription scheme. Following this, we discuss schemes that predominantly use fiction and poetry resources, and which focus on the more social aspects of group bibliotherapy. We outline the most widely-known UK scheme of this type: The Reader’s Shared Reading approach. We then discuss an alternative approach, «the Kirklees model», which adopts a more person-centred (rather than resource/literature-centred) process. Finally, we reflect on possible directions for the future development of bibliotherapy in the UK.
Since the term «bibliotherapy» was coined by Samuel McCord Crothers in his article «A Literary Clinic», published in the journal Atlantic Monthly in 1916, it has evolved in line with the changing roles of hospitals, schools, public libraries and other community institutions, reflecting how attitudes towards physical and mental health have altered across a range of professions and academic disciplines. The preliminary underpinnings of the concept of bibliotherapy began with the reform of asylums for the mentally ill in the nineteenth century. Psychiatry at this time was a fledgling discipline, and mental health problems were seen as moral defects rather than as being medically treatable (Porter, 2002). Attitudes to mental health started to change, with the medical profession stepping in to reframe «lunatics» as patients and asylums as a place for safe restraint rather than incarceration (Shorter, 1997). In fact, before the term bibliotherapy was coined, advocates of the humane treatment of mentally ill patients in asylums recommended reading as part of revised treatment regimens (Weimerskirch, 1965).
World War I proved to be a key event in the development of bibliotherapy. The high number of cases of «shell shock» and the rapid rise in the number of men experiencing psychological trauma at this time led to new understandings of the causes of mental health issues and new approaches to treating problems (Bourke, 2000; Shephard, 2002). Physiological explanations of mental health issues, the idea that a person could break down under stress, were more broadly accepted and psychotherapy expanded as an appropriate treatment.
However, occupational therapy, or interventions to support patients with activities with a view to getting them back to everyday life, was still in early development at this time. Instead, hospitals relied on non-medical staff, often librarians, to keep patients engaged with the world outside the hospital. This often involved providing books which gave patients guidance on developing new skills or interests, a process which was defined by Dorothy Hoskins Smith, a hospital librarian, as «remotivation» (Alston, 1962). Most of the focus at this time in the UK, as well as elsewhere, appears to have been on enthusiastic hospital librarians who wanted to improve mental health outcomes for their patients. This form of bibliotherapy could be conducted through one-to-one recommendations for patients or as a group discussion, though its focus was not on providing information about recovery.
Before the 1940s, books used for bibliotherapy could be fiction or non-fiction, but were often unconnected to mental health. As the field developed, however, librarians were more likely to try to classify books that might be recommended for particular themes or diagnoses. For example, Rubin (1978) recommended books for people who need help with decision-making, courage and despair. For a more detailed description of the history of bibliotherapy, see Brewster (2018).
This idea of recommending books based on a diagnosis, or the broader health-related need of an individual, was key to the development of self-help bibliotherapy. This encouraged a new model, which was first taken forward into UK public libraries in the early 2000s. The first Books on Prescription schemes began in Wales, with a pilot scheme in public libraries in the Welsh capital, Cardiff, in 2003, with UK-wide roll out following in 2005. It quickly became the most widely used model of bibliotherapy in the country, with over 100 public library authorities having a scheme.
Books on Prescription was designed to provide a list of self-help titles recommended by mental health professionals in a format that could be easily accessed through public library services. This widely-used model was popular from the start because it is simple to deliver. General Practitioners (GPs) and other health professionals could prescribe books included in the scheme to patients they felt might benefit via a paper prescription system, with the books then available to borrow from the local public library. The list mainly included books outlining cognitive behavioural therapy techniques on a number of specific conditions, including depression, anxiety and stress. Run in partnership between public library authorities and local health services, the aim was to recommend a specific book to a patient who health professionals felt would benefit from following the techniques and approach described in the written resource. Library users could also self-prescribe these titles, choosing to borrow them from the public library without a prescription from a health professional.
The introduction of Books on Prescription was informed, in part, by the NICE (National Institute for Health and Care Excellence) recommended guidelines for treatment for depression, anxiety and bulimia nervosa (NICE, 2004a, 2004b, 2004c, 2009). NICE’s recommendation of written resources for treatment in these conditions, combined with the low set-up costs of delivering these resources via the public library, was a strong incentive for trialling this approach. The Books on Prescription model was seen as a cost effective option because books are durable, inexpensive, and can be accessed by multiple library users. Access to psychological therapies in the UK at this time was limited, and psychiatrist Dr Neil Frude, who initially suggested partnering public libraries with medical professionals, was passionate in his vision that Books on Prescription would help more people to get the psychological support they needed (Frude, 2004, 2005, 2008). Furthermore, psychological interventions such as this are usually more popular with patients than medication.
In many ways Books on Prescription echoed earlier models of bibliotherapy, aiming to provide access to a list of recommended titles for different issues and conditions. However, the selection of titles was clinician-led; Frude initially consulted clinical psychiatrists and psychologists to form the list of recommended books. This model therefore differed in approach from previous lists of recommended resources which tended to be compiled by librarians or library academics (Clifford et al., 1999; Johnson, 1998; Rubin, 1978). Books on Prescription was designed to respond to treatment access issues for people with low-level mental health problems, providing an opportunity to access some support while on waiting lists for further treatment or following a referral. However, one drawback of the scheme was that because the books all aim to provide support for one defined condition, there were difficulties in recommending them for people with comorbidities (e.g. with depression and anxiety).
Analysis of borrowing figures have demonstrated a high demand for Books on Prescription titles, and responses to annual national evaluations have continued to suggest high levels of satisfaction with the scheme (Hicks, 2006; Porter et al., 2006; The Reading Agency et al., 2016). However, while this ongoing evaluation demonstrates that those who completed the survey felt that their understanding of their mental health problem and their confidence around managing the condition had improved, it has proved difficult to demonstrate an overall impact in terms of symptom reduction or decreased burden on mental health services.
Public librarians consulted on their involvement in the early incarnation of Books on Prescription were broadly positive about the approach, but expressed some concerns about its delivery in practice (Brewster, 2007). Many of the books on initial Books on Prescription scheme lists, selected by clinicians, were criticised by librarians for being outdated or less appropriate to their complex community needs. For example, often books had a very high reading age, making them less accessible to readers with lower literacy levels; a lack of suitable resources in community languages was also noted (Brewster, 2007). Grundy’s (2005) research found that UK readers disliked the American tone of some books, which meant they found them difficult to identify with. As the scheme has developed, collections have been refreshed and there has been greater consultation with readers, as well as library and clinical professionals, to ensure recommended resources meet identified needs.
However, improving engagement with Books on Prescription by medical professionals has been an ongoing challenge. There was a feeling from public librarians that greater involvement of medical professionals at the point of prescription was needed to ensure success. The high number of self-prescriptions in comparison with the number of prescriptions from GPs shows the difficulties in engaging GPs in new initiatives outside the health sector.
In 2013, the Books on Prescription scheme was revised and re-launched by a charity, The Reading Agency, as Reading Well Books on Prescription. It is currently offered by 99% of English public libraries and has been part of the Society of Chief Librarians’ Public Library Universal Health Offer since 2013. Under this guise, the scheme has expanded from is core aim of providing resources for common mental health conditions for adults. There is now also a recommended collection of fiction and self-help titles for people with dementia, their families and carers which launched in 2015 (Walworth, 2018a). For young people aged 13 to 18, there is a collection of self-help titles, with some recommended fiction known as shelf help, which covers a range of topics including confidence, self-esteem, anxiety and bullying (Walworth, 2018b). In July 2017, a collection of Books on Prescription titles was added for people with long-term conditions including diabetes, heart disease, and arthritis. This collection was co-produced with people with experience of living with long-term conditions, and includes titles covering specific symptoms such as pain and fatigue. The inclusion of titles chosen by readers with personal experience of the conditions under discussion represents an evolution within bibliotherapy, with the expertise of patients and readers recognised as a legitimate source of knowledge, alongside that of clinicians.
Whilst Books on Prescription places emphasis on self-help books that may support people living with particular diagnosed conditions, an alternative approach to bibliotherapy, which has also become popular in the UK, focuses on the use of fictional texts and poetry. The early 2000s were a fertile time for new models of bibliotherapy in the UK as using reading as a creative therapy became popular in public libraries and health services. Interest in using fiction and poetry as a form of bibliotherapy is also shown in The Reading Agency’s annual list of Mood Boosting Books. Chosen by readers and reading groups, the aim of this list is to provide a selection of titles that are uplifting. It is difficult to evaluate the impact of this scheme on people with mental health conditions, but attempts to synthesis the evidence base around using fiction and poetry conclude that it can contribute to increased cultural and social capital (The Reading Agency and BOP Consulting, 2015).
Although not as widespread as the Books on Prescription scheme, approaches to group reading and shared reading for wellbeing have become well-established in the UK, as well as elsewhere. These schemes usually work with groups of people rather than an individual reader. Previous research has established that reading has the potential to be relaxing, transportive and escapist (Billington et al, 2010; Brewster, 2017). It can also facilitate an emotional connection between the reader and the text (Rosenblatt, 1938; Cohen, 1994). In a group setting, the relationship between the group members also has a role to play in determining therapeutic outcomes (Brewster, 2011; Dowrick, 2012; Longden et al., 2015). Increased confidence and social inclusion have also been reported as outcomes of these types of schemes (Morral, 2016).
Most commonly, group reading schemes are designed to support people with mental health problems. Groups are held in variety of settings. Some schemes are designed exclusively for individuals who are receiving medical/healthcare support for mental health conditions, for example on psychiatric wards or in other health care settings. In other cases, bibliotherapy groups take place in a community setting, such as a library or community centre, and may include people with a diagnosed mental health condition alongside those without a medical diagnosis (or who do not wish to disclose a diagnosis), or who are experiencing more general wellbeing-related concerns. In general, however, this type of bibliotherapy tends to take a less focused approach – it is more about improving general wellbeing than providing people with techniques to help them to manage specific conditions.
Whilst Books on Prescription was initially led by psychiatrists and psychologists, bibliotherapy schemes that focus on fiction and poetry are more often devised by individuals with expertise in literature and/or education. A notable example is Shared Reading (initially called Get Into Reading) which was designed by Jane Davis, an English teacher working in the Department of Continuing Education at the University of Liverpool in the north-west of England. Her intention was to encourage people to engage with, and enjoy, «classic» literature that they might not otherwise have read, with a view that the universal themes within this type of literature could speak to all. The vision of The Reader, the organisation she set up, is party educational, and partly about improving well-being – giving people the skills and confidence to read, discuss and relate literature to their lives. The model rests on shared reading groups, initially run in public libraries, day centres and in-patient wards.
Importantly, in contrast to some self-help based forms of bibliotherapy, schemes such as Shared Reading do not expect to find simple literal answers or comfortable solutions to perceived problems. This type of bibliotherapy has different aims, being focused on the value of deep mental involvement and seeking meaning in a broad sense.
The Reader predominantly uses literary works that they refer to as «great literature», for example, George Eliot, Doris Lessing, Jane Austin, William Shakespeare and Charles Dickens (Dowrick et al., 2012). With its basis in literature and education, The Reader places value judgements on fiction and poetry with which not all may agree. Nevertheless, its approach has been popular and successful. The Reader’s Shared Reading model has spread nationally and internationally, with a focus on providing training and volunteer-led projects as well as delivering Shared Reading in diverse settings.
An assessment of the cultural value of Shared Reading identified five intrinsic elements of the experience that help to explain the theory underpinning the model. The first is liveliness: in contrast to many traditional reading groups, the texts in a Shared Reading group are read aloud rather than being read in advance. This model has been described as «a form of immediate doing, rather than solitary interpretation in measured retrospect» (Longden et al, 2015; emphasis in original). There is, therefore, an element of unpredictability as group members respond to the texts in a very immediate way. The second element is «creative inarticulacy»: in contrast to self-help books in which the procedure is top down in terms of the naming of procedures, treatments and so forth, in this model, language tends to be much more uncertain and tentative as group members try to find ways of expressing emergent ideas. The third element of Shared Reading is the importance of the emotional: demonstrating the «use» of literature, but in an affective, rather than an instrumental, sense. The fourth element is the way in which literature can prompt personal stories, or «self-disclosing talk» (Longden et al, 2015). Although the text is fictional, it can feel very real when read aloud, prompting participants to shift from outward attention to inward attention as they review their own experiences in the light of the literary context. The final element underpinning the model is the group itself, in particular, similarities and differences in their responses to the text.
The two forms of bibliotherapy described so far, Books on Prescription and Shared Reading, have been the most common approaches in the UK for the best part of two decades. Whilst they differ in many ways, a feature they share is that they place a clear emphasis on the text as a starting point for the intervention. In the case of Books on Prescription, texts are selected (by clinicians, or by patients and readers) to provide support with an identified condition or experience. In the Shared Reading model, texts are selected using very different criteria, namely, their literary «quality» and potential to stimulate deep mental involvement. This is perhaps unsurprising given these approaches were founded by clinicians and literary educators respectively. However, there is also a third model of bibliotherapy to be found in the UK. This model, which we call here the «Kirklees model», takes an approach more rooted in care professions and community work traditions. Rather than taking the text as its starting point, it is grounded around the experiences and needs of individuals taking part in the scheme.
Bibliotherapy schemes began operating in Kirklees in West Yorkshire in northern England in 2000, with the appointment of three dedicated bibliotherapists who were employed part-time within the public library service. Their backgrounds and previous experience were diverse – social work, education and librarianship – but they all shared a passion for connecting people with texts. The scheme, initially know as RAYS, the Reading And You Scheme, and later as Well into Words, has worked in public libraries, and in day services and in-patient wards for people with mental health issues or dementia. The model encompasses many different elements, including:
The poetry and fiction used in the Kirklees model is highly diverse, and unlike many bibliotherapy schemes, there is not a list of recommended titles. Instead, the bibliotherapists work from the needs of individuals and groups to connect readers with books.
For a number of years, Kirklees public library service was innovative in being the only public library service in the UK to employ bibliotherapists with a specific remit to deliver group sessions on an ongoing basis. In 2016, however, this role was dissolved and it became part of Kirklees librarians’ outreach work to deliver bibliotherapy sessions. In addition, Third Sector Leaders Kirklees, an organisation which manages a number of local volunteer schemes, applied for funding to run a bibliotherapy scheme using fiction, poetry and other creative resources for people with mental health problems and people with dementia, using a volunteer-led model. This funding application was successful, and in 2018, this scheme, Words in Mind, started to offer bibliotherapy sessions in Kirklees. For a more detailed account of the history of bibliotherapy in Kirklees, see Brewster and McNicol (2020).
Words in Mind can be seen as evolving from this history of bibliotherapy provision across the district. The Words in Mind scheme is delivered by volunteers and sessional workers, who are trained to run bibliotherapy groups for people with dementia and/or people with mental health problems around Kirklees. Groups are run in various locations: NHS (National Health Service) care settings including an inpatient rehabilitation unit for people with severe mental health problems; community centres; residential care homes for elderly people; public libraries; in partnership with organisations that support recovery from mental health problems; and as part of established support groups, such as a group for people with young onset dementia. All are delivered by one or two facilitators, who lead each group.
Unlike other approaches to bibliotherapy, the Kirklees approach takes a more open and diverse stance in response to the question: «What is bibliotherapy?». This approach is markedly different from models such as Shared Reading (described above), for example, which places strong emphasis on the importance of written texts, only rarely drawing on visual imagery or song. In contrast, the Kirklees model is focused on using diverse forms of resources to engage people with words.
The Kirklees model of bibliotherapy is, therefore, fundamentally diverse and tailored to participants in each group. The starting point in planning a session is the needs of participants (rather than the literature or other texts which are used). This takes various forms in practice. Some groups include more discussion, while others make regular use of other media or activities. In some groups, members select and bring their own texts, whilst in other cases most resources are provided by the facilitator. Some participants produce their own writing which can be shared with the group. Finally, some groups adopt an inclusive and shared approach to reading aloud, while in others the facilitator reads. We describe this as a «person-centred» approach, drawing on understandings of service delivery in health and social care (Mead and Bower, 2000).
Fundamentally, the direction of each bibliotherapy session is shaped by the group members, guided by the group facilitator, and tailored to their needs and interests. The variety of group sessions can be seen as a strength of the Kirklees model, in that it allows facilitators to meet particular needs and be responsive to the group. Indeed, there is an awareness amongst facilitators that even within a single group, experiences can vary week by week depending on the mood of those attending. However, whilst this tailoring makes the Kirklees model a diverse and versatile intervention, it can lead to uncertainty from external organisations involved in the scheme about what to expect from a bibliotherapy group, as there is no single model to describe – as is more usually the case for bibliotherapy interventions.
In-keeping with the person-centred nature of bibliotherapy in Kirklees, sessions are co-produced between facilitators and participants. In some groups, facilitators act more as a group member, for example, sharing their own writing alongside other participants. In addition, group members frequently bring along texts to read, choose themes for the sessions, or help to devise other activities such as quizzes. In some groups, a lot of time is given over to sharing of experiences in relation to the resources, while others focus more on the content of the resources shared. There is scope to engage with images, sensory resources (things to smell or touch), and reviewing song lyrics (and singing or listening to songs) alongside more traditional poems, short stories and extracts from novels. In some groups, for example, those in care homes, co-production typically occurs in more spontaneous ways. Amongst people living with dementia, some texts, especially poems, might bring a sense of recognition and stimulate memories, for example, remembering poems they had read at school and reciting lines from these. This recognition and response then shapes the direction of the group. This leads to a clear sense of «ownership» in the groups: the group belongs to participants and is shaped by their needs.
The idea of making a contribution and relating to literature, and to each other, is therefore central to the Kirklees model of bibliotherapy. Contribution can take many different forms: group members reading parts of a text aloud; bringing texts along to the session; contributing to discussions about the text; or supporting other group members as they share some insights about the text or their own lives. Participants are each able to decide how they wish to contribute, but all contributions are valued. There is awareness amongst those involved in the scheme that «involvement» might look very different for different groups. For some participants in care homes, for example, involvement might simply involve making eye contact or being aware of what is going on around them.
Connected to this idea of being able to contribute, a benefit of the bibliotherapy groups for many participants is increased confidence. For some, this might be confidence to read aloud, especially for people with health conditions that might make this challenging. In groups where participants share their own writing, many grow in confidence as they feel more able to share short pieces of writing and express their thoughts in a format they might not have felt able to engage with previously.
Another aspect of the sessions that relates to the person-centred nature of the Kirklees model is the opportunities it brings for social interaction. In common with other group bibliotherapy models (e.g. Shared Reading), one of the most obvious social benefits of the sessions run in Kirklees is increased opportunities to interact with other people, especially for participants who lack opportunities to do so at other times of the week. Through literature, participants are able to reflect on their own lives in different ways, such as by identifying with characters or emotions in a text, and by finding new ways to express themselves, for example, as a means of talking about how they were feeling, but with a degree of distance.
Crucially, the sessions provide a safe space where people feel relaxed, comfortable and respected. Bibliotherapy sessions have been described as a place where «you’re treated as a human being with value and that you’re cared about, and that whatever you're feeling are important and worth sharing with people» (interviewee quoted in Brewster and McNicol, 2020). Participants in many of the groups have become friends and support each other in numerous ways outside the sessions, as well as within them.
In Kirklees model, therefore, bibliotherapy sessions start from the needs of participants, rather than from texts that have been chosen according to either medically-based or literary criteria. However, this does not mean that the texts themselves are unimportant. The sessions do encourage greater awareness and understanding of literature and culture, but this is defined widely and is intended to be inclusive, including for people who may not have considered themselves to be «readers». The notion of «text» or «literature» therefore includes a wider range of materials and media than is often the case in bibliotherapy interventions.
This range of resources, both in terms of type and format, reinforces the flexibility of the Kirklees approach. Facilitators tend to take a lot of material to sessions, even if, in practice, they might only use a single poem. The pace of the session, and the number of resources used, varies considerably from session to session, and can be difficult to predict. Facilitators put a great deal of time and effort into the selection of resources for their sessions, and most draw on a wide variety of texts and resources, with session plans showing up to 20 potential resources which they may draw on depending on the needs and mood of group members. Whilst the resources used vary from session to session and group to group, they commonly include «classic» or well-known books and poems; less widely known texts; «popular» texts (e.g. funny poems); lyrics; quotes; images; newspaper/magazine articles; local history resources; short stories/ quick reads; and (auto)biographies. Importantly, resources are not only provided by the facilitator, but often by group members too. Furthermore, facilitators realise that the fact that a text had not worked well with a particular group does not necessarily mean it would not be appreciated on a different occasion by another group.
Sessions in care homes, in particular, typically include a range of media, such as images, objects/props, large print/picture books and reminiscence resources. Session might also include games, quizzes and singing, or simple activities like the creation of a «memory jar». Facilitators also make use of objects, particularly those that might stimulate a range of senses, for example, flowers to smell, pebbles to touch, or fruit to taste.
There are also attempts to provide diverse resources, for example, reflecting different cultures and genders. In addition, the resources selected for sessions vary in length and complexity. Some facilitators have a «fall-back» resource, such as a poetry anthology, which they use if they need additional materials, and many bring printed copies of some of the texts they intend to read for participants to follow along and take away if they wish.
Importantly, facilitators do not place value judgements on the resources; their use is more about encouraging engagement. Equally, no judgements are made about the ways that individuals engage with the resources: listening, expressing opinions about the resources (positively or negatively), or even simply maintaining eye contact can be equally valid forms of engagement depending on the group or the individual concerned.
Current UK models of self-help bibliotherapy and bibliotherapy using fiction and poetry have had great influence on current models of bibliotherapy internationally. Books on Prescription is available in many public libraries in the USA, and The Reader’s Shared Reading model has been adopted in Australia, Belgium, the Netherlands, Germany and Denmark. The text-centred and more structured nature of these bibliotherapy models potentially makes them relatively easy to disseminate and translate to other settings. It is, perhaps, for this reason that more person-centred approaches to bibliotherapy have not been as widely taken up as yet.
In this article, we have outlined the overall development of bibliotherapy approaches in the UK, but focused attention on the «Kirklees model» of bibliotherapy as we believe that this approach is indicative of the ways in which bibliotherapy may develop in the UK in the future.
In the past, the main audiences for bibliotherapy have tended to be well-educated, and predominantly White and female. In recent years, however, there has been growing interest engaging with more diverse audiences such as homeless populations, psychiatric patients, speakers of other languages and people living with dementia, thus widening the appeal of bibliotherapy.
As far back as the 1940s, Estelle Brodman (quoted in Hynes, 1972) commented, «patients’ librarians…should study not books, but people». In the intervening years, however, many schemes and approaches appear to have placed more emphasis on the texts used than on the people reading them. Recent incarnations of bibliotherapy (both self-help and fiction- / poetry-based) have taken what could be seen as a less inclusive approach by making stringent judgements about what materials are appropriate for use in bibliotherapy. For example, research into a literature-based intervention for older people living with dementia only refers briefly to the use of non-word based resources, and there is a strong sense that these are seen as inferior to word-based resources, being described as «an extra stimulus for group members that would help them re-engage» rather than being of value as texts in their own right (Centre for Research into Reading Information and Linguistic Systems, 2012).
As the most common bibliotherapy activities focus on the use of written texts, whether in the form of novels, poetry or self-help books, research into the use of alternative forms of «text» is limited. In recent years, however, there has been a growing interest in the use of graphic novels and comics as a mode of bibliotherapy. Research has shown that comics can provide a sense of companionship, reassurance and recognition through the realisation that others are dealing with the same issues, making the format potentially valuable as a bibliotherapy resource (McNicol, 2018). However, there is very little research into the impact of other types of bibliotherapy resources, such as objects or sensory resources.
A new project that demonstrates the way in which bibliotherapy in the UK appears to be moving towards more person-centred approaches is the Scottish Book Trust’s «Reading is Caring». This is a pilot project, which, although it has been developed independently, shares several aspects of the overall ethos of the Kirklees model. It is a shared reading model based on a one-to-one intervention involving a person with dementia and their carer (familial or professional), rather than group sessions. It very much places the individual at the heart of the experience, with the choice of texts being selected in response to their needs and interests. The emphasis in this project is on helping the individual living with dementia, and their carer, to reconnect and maintain – or enhance - their relationship. Training developed for Reading is Caring encourages the use of a variety of resources: more traditional bibliotherapy texts such as poetry and short stories, but also cartoons, scripts, images, newspapers, magazines, photographs, recipes, lyrics, objects etc. A central aspect of the approach is the creation of a «life story book box» that includes a variety of objects and resources likely to be of interest to the person with dementia, for example, items with links to their hobbies, childhood, working life, family and holidays. The shared reading material is therefore tailored to the person with dementia and chosen by family members and others who know them well.
As with the Kirkless model, therefore, Reading is Caring adopts a person-centred approach to bibliotherapy in which the choice of texts is important, but only in relation to how they are likely to engage, and draw responses from, participants, rather than from any more detached judgements of their literary, or other, qualities.
There is undoubtedly a place for all the forms of bibliotherapy described in this chapter: the success of Books on Prescription and Shared Reading is evidence of that. However, it is hoped that an increasing interest in more person-centred approaches will enable a widening of the audiences who want to engage with, and can benefit from, bibliotherapy. By shifting attention away from the reading materials used and towards the participants, these types of approaches lead us to question what is meant by a «text». Models of bibliotherapy such as the Kirklees model and Reading is Caring therefore build on our existing knowledge of bibliotherapy developed during the course of its long history, but crucially they widen the definition of text to help us to explore how a more inclusive attitude towards resources used within bibliotherapy programmes that might benefit people’s wellbeing in new ways.
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No conflicts of interest declared.
This manuscript was approved by Cristina Deberti.
Both authors contributed equally to the writing to this article, and to the conception, design and analysis of the research underpinning it. The evaluation of Words in Mind, on which parts of this article are based, was supported by Words in Mind. The funder played no role in the design, execution, analysis and interpretation of the data, or writing of the study.