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The reading remedy: bibliotherapy in practice.

Bibliotherapy is an umbrella term for related ideas for using books to help people with mental and physical health problems. The beginnings of bibliotherapeutic work are examined, and developments involving public libraries in the UK reviewed. It is concluded that the infrastructure of bibliotherapy schemes is already present in the day to day operation of a public library service, and that most depressed people may benefit from bibliotherapeutic interaction. From a 2007 research project three subsections of bibliotherapeutic practice emerged. These are self help bibliotherapy, creative bibliotherapy and informal bibliotherapy.

This is the second of three articles published in Aplis. It is published with the permission of the editor of the 'Public library journal' in which it first appeared. The first article was 'Medicine for the soul: bibliotherapy' Aplis 21(3) September 2008 pp 115-119.

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Bibliotherapy is a diverse concept, but one relevant to the aims and objectives of librarianship in the 21st century. The basic premise of bibliotherapeutic work is to provide health information and support using books. At the moment the focus of this endeavour is to supply this information for people with mental health difficulties like depression and anxiety. But it can be expanded to include any medical condition, from obesity to diabetes, that may benefit from monitored self care. Using prescribed self help books to help people with illnesses such as depression is supported within the UK's National Institute for Health and Clinical Excellence guidelines on the subject. However there has so far been limited recent research into the practical application of using books to help people.

Bibliotheraputic work also includes working more closely with people and fiction books to impact on people's lives and help them find both pleasure in reading, and release from mental illness. This can include working in groups and on a one to one basis with people, helping them to rediscover--or to discover for the first time--a love of literature. This aspect of bibliotherapeutic work can be viewed as a service that libraries provide anyway--their reader development work and engaging people with fiction and poetry to provide enjoyment, makes, from anecdotal evidence, a contribution to people's mental health and well being.

Libraries are in a unique position to provide input to schemes to provide free access to self help books on the recommendation of the medical profession. A number of UK public library services have set up schemes under the banner of Books on Prescription to enable library users to borrow books, but as yet there is not a national scheme in England or Scotland within which librarians can work. Books on Prescription has become national throughout Wales, having begun in Cardiff in 2003. It allows libraries to contribute to the wide remit of increasing the wellbeing of the community as a whole. The UK's Museums Libraries and Archives refers to the importance of the involvement of the library, stating that
   health is more than the absence of illness. The
   ability to learn, to be creative, to develop
   personally and grow life skills are part of mental
   wellbeing and help sustain it. (1)


The recommendations outlined in this article emerged from a research project carried out between January and September 2007. From the project, three subsections of bibliotherapeutic practice emerged

* self help bibliotherapy--the prescription of nonfiction, advisory books about mental health conditions like depression

* creative bibliotherapy--the use of fiction, poetry, biographical writing and creative writing to improve mental health and well being

* informal bibliotherapy--a focus on creative bibliotherapy techniques in an unstructured manner, including the use of reading groups, recommendations from staff and displays in the library. This approach can be strengthened by close relationships between librarians and their communities.

Outline of the research project

The research was conducted from a perspective examining the importance of language to our ideas and concepts. The postmodern nature of this approach enabled a recognition of the shortcomings of understanding that emerge from research. As the aim was to collect and understand the opinions of staff, a qualitative approach was taken, using indepth interviews to ascertain views and practices. These conversations took place in the UK summer of 2007, and were predominantly conducted with professional library staff who had been involved in the implementation or day to day running of schemes with bibliotherapeutic aims in various areas of the UK. These interviews enabled a number of recommendations for practice to be put forward, and raised a number of issues common to those working in bibliotherapeutic practice.

This article focuses on self help bibliotherapy, explaining practical methods for taking projects further. These recommendations are based on experiences recorded in the interviews and analysis of the extensive medical literature surrounding the subject.

Common concerns and ideas

Both self help and creative bibliotherapy contribute to the wider agenda of current library practice. They encourage social inclusion and can be seen to help reduce the stigma surrounding mental health in society. However, bibliotherapy as a whole needs to be defined and structured more clearly. While the variety of approaches and ideas allows libraries to experiment with the scheme, the variety of successes and failures within the schemes suggests that some kind of national standards or guidelines need to be implemented to enable librarians to put bibliotherapeutic schemes into practice which are of optimal benefit to their communities.

The overall problems with the lack of a clear definition of bibliotherapy mean that different authorities offer different services under the same name. While the Books on Prescription scheme has helped to unify self help bibliotherapy under one banner, the confusion over terminology causes uncertainty amongst staff, who are aware of bibliotherapy as a service but are not sure if they are providing it themselves.

Most of the self help bibliotherapy schemes in question were instigated in partnership with a local National Health Service (NHS) trust, bringing up a number of issues connected with partnership working. Goulding (2) states that partnership working helps libraries to modernise and provides access to funding, client groups and further relationships. Some authorities found that working in partnership entitled them to bid for funding that had previously been unavailable to them, but others found that they were expected to foot the bill for a hitherto unexpected purchase and publicity of a collection of books. Partnership working proved to be an important aspect of all the schemes studied, with many of the difficulties implementing the schemes connected to breakdowns in communication between partners. It was noted that the health service does not always recognise that the library service has assistance to offer within the sphere of treatment, and so wider publicity and advocacy may be necessary to improve perceptions and relationships.

Recommendations

The endorsement of the National Institute for Health and Clinical Excellence for the use of self help books to support people with mild to moderate depression and other mild mental health conditions should encourage UK libraries to be involved with schemes to distribute suitable books. Libraries already have locations at the heart of the community, providing literature, information and support to their users. It makes perfect sense to join up the dots between healthcare provision and libraries to promote self help bibliotherapy. Rolling the scheme out on a national level would help to avoid problems encountered in different regions, and provide support to library staff unsure as to the best way to begin their scheme. It would also encourage health care providers to acknowledge the services that libraries can provide
   We've had good feedback from people who've
   borrowed the books, they feel like they're
   helping themselves rather than taking medication
   year after year. (research participant)


While the schemes in question focus on mental health within the community, rather than health in general, Books on Prescription was seen as an integral part of the overall agenda
   I think it's such a massive area to be tackled that
   I think that anything we do that can contribute
   towards that is definitely a good thing. (research
   participant)


Best practice

We need to share ideas. As most bibliotherapy schemes are still in their infancy, it seems necessary that there is an increase in the sharing of best practice. While the JISCmail bibliotherapy list is a useful tool, (3) further research into the subject and the dissemination of information via conferences would also help to improve services and share knowledge.

Many of the library staff interviewed commented on the individual quirks of schemes in their area, but seemed unaware of practices in other areas.

The sharing of best practice would also help to solve common problems. The provision of self help material in minority languages was a thread emerging from the research that requires further investigation, both in terms of supply and demand
   There are gaps in it. There's nothing in Asian
   languages, tot" example, about teenage
   pregnancy. (research participant)

   We've only found one of those 40 books that is
   published in minority ethnic languages ... One of
   the big problems is people wondering where
   they're going to get these alternative formats
   from, they just don't exist. (research participant)


The sharing of experiences and titles would save time and money for library services in similar situations. It would also provide a system of support for those librarians considering starting schemes in their own areas, and allow them to avoid some of the pitfalls encountered by others.

Training

Another recommendation to be considered is that training on mental health issues is important for library staff to help them provide a better service to all users and to help create a wider understanding of the potential for bibliotherapy schemes. With one in four people in Britain suffering mental illness--from mild depression to more serious conditions at some point during their lives, it seems important for libraries to provide a service to those experiencing mental illness. The simple presence of the schemes in a location accessible to all helps to reduce the stigma attached to mental health problems. This can only be a good thing.

Training needs of staff were seen as simple and easy to implement. The Books on Prescription scheme is fundamentally straightforward to manage from the point of view of the library staff who would be dealing with prescriptions and interacting with customers. It was seen as more important to explain the context of the project to stall" than the way the project would be instigated
   That [training] was on issues around the whole
   general area of mental health and why books
   were perceived to be useful in combating mental
   health problems; the background to the scheme,
   about Cardiff and so on, and how we were
   proposing to administer it, and the various bits of
   stationery involved. Basically it's very easy to
   operate. (research participant)


Hicks (4) found a similar picture, with the main locus on training regarding mental health issues.

Partnership working

The importance of successful partnerships between healthcare providers and libraries emerged from the research. There needs to be more communication between health authorities and library services to ensure that both partners are clear about responsibilities, promotion and funding provision. While the cooperation between doctors surgeries and libraries was essential for the Books on Prescription model described above, this was not the only model that emerged from the research, as will be discussed in the section on self referral. Nevertheless, it was mostly felt that a partnership was necessary.
   I do think that the library has a role but I do think
   that it needs to be backed up by someone who
   knows about mental health. (research
   participant)


The role of partnerships was clarified by need to have a medical voice contained within the provision of books for the library service. The confidence that staff could have in the professional partnerships within the scheme was also reported as a positive outcome.
   We had one girl who was severely anorexic and
   we were able to say 'these are really good self
   help books' ... you can have confidence in your
   product which is always useful. (research
   participant)


Nevertheless, the need for the expertise of library staff in sourcing titles and recognising the needs of the community was visible in comments about the lack of titles available in different languages. Libraries need to remember that while healthcare authorities know about mental health, they know about books. Both kinds of knowledge are necessary to implement such schemes.

Self referral

Several authorities found that despite the lack of success with their partnership with the health authority, the provision of self help literature encouraged the self prescription of books by members of the community. This illustrates that having Books on Prescription books on the open shelves has unexpected benefits, and presents an argument against closed collections.
   I would hope that people are becoming more
   aware that one in five of us, is it, suffers mental
   health issues ... I just think that if we have those
   books that are on the open shelves that are very
   accessible, on display, it will become part of
   what we all expect. (research participant)


Numerous librarians in charge of running Books on Prescription schemes found that users were coming to the library independently and obviously did not feel that there was a stigma attached to borrowing such books.
   One thing we have discovered is that people are
   almost all self referring, they're just coming to
   the shelves and taking them off ... they can just
   take it away without tear of being judged by
   anybody. (research participant)

   Something like 10% of the books were issued by
   prescription, 90% were taken by the general
   public. (research participant)


This unexpected outcome shows that the addition of the books to the collection, and the publicising of such a scheme has had a positive effect on the community, although one that is difficult to measure. While many research participants felt that there was still a stigma attached to mental health and borrowing books on the subject, the response of the general public to their access to self help texts illustrates that people welcome the opportunity to borrow such texts.

Evaluation

One worrying aspect that emerged from the research is that there has been little or no evaluation of the effect and success of the schemes set up so far. The statistics collected illustrate the number of books issued, number of prescriptions written, and so forth, but there needs to be more investigation into the outcome for library users of borrowing the books.
   There's practically nothing we can do to see how
   much good this sort of thing is actually doing the
   patients--the customers. It's quite extraordinary,
   in a way, that this kind of thing has mushroomed
   all over the country ... and we still don't have, to
   my knowledge, a thorough survey of how much
   good they're doing the people that actually use
   them. (research participant)


While it can very difficult to get people to talk about their personal reactions to books, it can be an idea to talk to borrowers about the effect that the books had on their wellbeing. Libraries need to learn what their users really think about the books that are being recommended so that they can strive to improve services. This is a question for further research as well as for anecdotal investigation within the library it is important to listen to what people want to say. But we need to remember that it is a sensitive subject, requiring the tact of a good librarian.

Funding

Any initiative that occurs in a library requires financial support. This can be sought from external sources as well as from within the library budget. There really cannot be a recommendation about funding it would be lovely to direct librarians to definite sources of funding, but this is impossible. However, the variety of sources of funding gained by the schemes studied in this research provide both hope and ideas for those looking to set up or expand schemes in their own area. Some library staff felt that providing schemes like self help and creative bibliotherapy was going beyond the call of duty for the library service, and that in the end it could harm other areas of library service provision.
   It takes a lot of resources and that means ...
   pulling resources away from frontline services.


There needs to be a balance between maintaining good service standards as well as expanding new services, but it needs to be remembered that innovation requires investment. Where schemes were run in partnership with health authorities, there was some disagreement when funding was required.
   What happened last time was that the funding
   paid for the publicity and a very modest launch.
   But the library service ended up paying for all
   the books, so we actually ended up footing the
   great majority of the bill. And to be quite candid,
   we're quite anxious not to do that again.


Lessons can be learnt here about making sure both partners in a scheme are clear about their role and the resources they are expected to contribute. However, some library services found that rather than costing money, the impetus from the primary care trust to set up a scheme actually enabled them to access funding that had previously not been open to the library.
   About two years ago someone put me in contact
   with colleagues in the primary care trust mental
   health department who'd got some spare funding
   that had to be used by the end of the year and
   they'd heard of Books on Prescription, so they
   thought it'd be a good idea if we did that.


While the concept of spare funding is uncommon in both the library service and the NHS, there are often opportunities to bid for funding for projects like Books on Prescription schemes that are beyond the normal remit of the library service or the health service. Creative bibliotherapy services also enable libraries to bid for a variety of funding.
   We had the funding from the Department of
   Culture Media and Sport, the Wolfson Libraries
   Challenge Fund, the primary care trusts and
   libraries ... then we got funding from the Arts
   Council.


This demonstrates the potential funding sources that can be encountered during the implementation of the projects and demonstrates that libraries can get money to try new things, like creative bibliotherapy. One measure of the scheme's success is that it eventually became fundamental to the library's provision of services
   Two years ago it became fully funded. So after
   five years, it became an integral part of the
   library services.


If nothing else, this shows that with patience and work, new services can be introduced that prove their worth. Libraries should have the courage to try, for the sake of their communities.

Finally

The quote below illustrates the difference that bibliotherapy can make to the lives of the local community and how it can promote library use. It summarises the importance of thinking outside the box to come up with new ideas, and working closely with those who might not typically use the library. It is taken from an incident described during a research interview into the creative bibliotherapy process. In this case, a man who had been recommended to the creative bibliotherapy scheme by his doctor--and went to the library under duress - was able to find an activity to share with his estranged young son, once he had discovered his own enjoyment of reading.
   I met him in the library one day with a little boy,
   and he says 'this is the ex girlfriend's son. Can
   he join the library?' So I said 'yes', and he said
   'because he likes dinosaurs' and the wee boy was
   saying 'dad, dad, can I have this book?' and you
   know, there they went, they went off together,
   and I thought that was fantastic.


This anecdote is one of the many heartwarming stories to emerge from the research project and shows that it can make a difference to the lives of the community as a whole.

The benefits of bibliotherapeutic services were emphasised by those who took part in the research. There were few negative comments about the services. These mainly reflected the management of the services and the difficulties of partnership working. While the research was not a nationally representative survey, the positive comments and potential of the service to help people illustrates a direction in which the library service can progress. It was unanimously agreed that the positive effects of bibliotherapy schemes on the community far outweighed the potential difficulties in implementing the schemes. Whether it is the pragmatic approach of self help bibliotherapy; teaching people to cope with emotions and problems; or the journey of self discovery that can be found within a fiction book recommended by a creative bibliotherapist, libraries have a role in providing the staff, services and structure that can benefit the population.

Public library work has always reflected the desire to address the social responsibility inherent in their function. Bibliotherapy schemes have the potential to make a real difference in this respect, providing 'medicine for the soul' in diverse and accessible ways to the whole community.

The final article, to appear in the March 2009 issue of Aplis, examines whether bibliotherapy is something that libraries do as a matter of course. It contains a discussion of creative and informal bibliotherapy, looking at reader development, readers groups and attitudes to social inclusion and interactions with users. It also considers whether, if libraries cannot afford to set up formal bibliotherapy schemes, there are methods of bringing bibliotherapeutic techniques into everyday library work.

Editor's note The first of the three articles on bibliotherapy by Liz Brewster 'Medicine for the soul: bibliotherapy' appeared in Aplis 21(3) September 2008 pp115-119. The third article will appear in the March 2009 issue of Aplis.

The full text of her dissertation is accessible at http://dagola.sheff.ac.uk/dissertations/2006-07/External/ Brewster_Elizabeth_MALib.pdf

Readers interested in bibliotherapy and public libraries are referred also to the article by June Turner 'Bibliotherapy for health and wellbeing: an effective investment'. This was published in Aplis 21(2) June 2008 pp56-61.

Also of interest will be Bernie McSwain's article in the June 2008 issue of Aplis pp62-65 'Bringing it all together: Salisbury reads'. This includes a description of the Prescribe Books initiative of the Salisbury Library Service in South Australia.

References

(1) MLA Promoting health 2008 www.mla.gov.uk/policy/Diversity/ People_With_Mental_Health_Issues

(2) Goulding, A Public libraries in the twenty first century: defining services and debating the future Aldershot, Ashgate 2006

(3) http://www.jiscmail.ac.uk/cgi-bin/quicktype.cgi

(4) Hicks, D An audit of bibliotherapy / Books on Prescription activities in England 2006 www.mla.gov.uk/resources/ assets/B/bibliotherapy_12779.pdf

Other reference

Sheldrick Ross, C, McKechnie, E and Rothbauer, P Reading matters. what the research reveals about reading, libraries and community London, Libraries Unlimited 2006

Liz Brewster PhD student University of Sheffield UK

Liz Brewster is a PhD student at the University of Sheffield, studying the relationship between libraries and bibliotherapeutic practice. In January 2008, she won the SINTO Bob Usherwood prize for research making a significant contribution to improving professional practice. Liz has previously worked for library services in Nottingham, Manchester and York. Address: 116 Greenhow Street Walkley Sheffield $6 3TP UK Email lizzy.brewster@gmail.com
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Author:Brewster, Liz
Publication:Australasian Public Libraries and Information Services
Date:Dec 1, 2008
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