A Short Guide for Professionals Using Bibliotherapy

What is Bibliotherapy?
The Rationale for Bibliotherapy
Self-help Books
CBT-based Books
Is Bibliotherapy Effective?

Who Might Benefit?
Advantages of Bibliotherapy
Limitations of Bibliotherapy


What is Bibliotherapy?
The use of books for therapeutic purposes is known as ‘bibliotherapy’. Self-help books have been used in this way for many years and are now being recommended as a means of providing psychological therapy for people experiencing emotional and psychological difficulties.

Bibliotherapy incorporates a philosophy of self-efficacy and user empowerment - attributes which form the foundation of most successful recovery programs. 

The Rationale for Bibliotherapy
Mental health difficulties are prevalent in Ireland with one in six of our population having a mental health need at any given time. Psychological therapies have been shown to be effective and beneficial for a range of emotional and mental health issues. However, in Ireland fewer than 10% of people with such difficulties get access to specialist mental health services or psychological therapies. The HSE has committed to providing greater access to psychological therapies. 

The effectiveness of bibliotherapy has been well established in many clinical trials. It is an immediately accessible treatment that is inexpensive and may be used flexibly. The reading material can act as an additional support to clients already working with a mental health professional; it may help clients on waiting lists for services or it may be used as a stand-alone psychological intervention. It may be used with or without medication. The families and carers of those experiencing difficulties may also utilise bibliotherapy as an additional resource.

There seems to be an appetite among Ireland people for bibliotherapy as evidenced by the number of listed books issued by participating libraries and the local schemes that have developed. Recent Irish research indicated that patients’ and providers’ experience of bibliotherapy was positive (McKenna, G., Hevey, D., Martin & E., 2010). The results of this study suggest that bibliotherapy offers a potentially valuable method through which adaptive strategies for recovery can be made widely and easily available. 

Self-help Books
There is a vast array of self-help books in existence. Many of these books are inspirational ‘feel good’ books; others focus on various types of 'self-improvement' (for example, how to become popular or how to gain promotion at work). The self-help books under discussion here address 'clinical' mental health problems, usually those of mild or moderate severity. Such books, for example, provide guidance to the reader on how to overcome anxiety, control anger or lift depression. The best of these books present self-help adaptations of established clinical treatment programmes in step-by-step form. They have been written by acknowledged experts in the field with years of relevant clinical and research experience.

Even high quality self-help books vary enormously in style, and it is unlikely that any one book will suit everyone with a particular problem. For example, a book that one person finds ‘very supportive’, may be experienced as ‘somewhat patronising’ by another. Some people will judge a highly structured book to be ‘straightforward’ while another person might reject it as ‘mechanical’. In compiling bibliotherapy lists books are identified which are likely to prove acceptable to a high proportion of the potential readership, but it is clearly not possible to cater for everyone.

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CBT-based Books

Most books on such bibliotherapy lists are based on Cognitive-Behavioural Therapy, often shortened to ‘CBT’. CBT works by helping people to identify and understand their own destructive thought and behavioural patterns and to revise them resulting in more rational and realistic thinking and behaviour. It is highly structured and very practical. It focuses on the ‘here and now’ and is a highly ‘transparent’ form of treatment. Extensive use is made of assessment and monitoring aids such as questionnaires and diary sheets.

A substantial body of research has shown cognitive behavioural therapy (CBT) to be highly effective in treating a range of psychological problems. Evidence for its effectiveness is robust and CBT is now widely accepted as a highly effective way of helping people to overcome emotional and behavioural conditions such as anxiety, depression, panic attacks and bulimia nervosa. It can be used as a stand-alone treatment, but it also works well in conjunction with medication.

The nature of CBT makes it well-suited to adaptation as a self-help form of therapy. Thus the majority of self-help books written by mental health professionals make extensive use of cognitive behaviour therapy (CBT) strategies.  

Is Bibliotherapy Effective?
Well-conducted effectiveness studies have taken place through controlled trials on particular books relating to depression, panic disorder, agoraphobia, bulimia nervosa, etc. Particular books have been deemed as effective as a full course of individual psychotherapy or as treatment with the best anti-depressant medication (Scogin, 2003). Although the results of these studies have generally indicated powerful therapeutic effects, they have also shown that the level of effectiveness depends to a very great extent on the quality of the book. Some books (used as controls in studies) have been shown to have no significant therapeutic effect.

Having reviewed all of the available evidence, the National Institute for Health & Clinical Excellence (NICE) in the UK (2004) concluded that high quality CBT-based bibliotherapy is often effective for the treatment of panic disorder, generalised anxiety disorder, mild and moderate depression, bulimia nervosa and binge eating disorder. NICE currently recommends the use of bibliotherapy (or ‘guided self-help’) at an early stage of stepped care programmes for these conditions (NICE, 2004a, 2004b, 2004c). Furthermore, NICE claimed that the quality of the evidence supporting the recommendation to make use of bibliotherapy was of the highest order.

Effectiveness depends not only on the quality of the book but also on the motivation and application (as well as the literacy) of the patient. Those who actively read the self-help material and enthusiastically complete a programme are more likely to benefit than those who only partially read the material and fail to complete the exercises or to carry out the recommendations. However, total adherence to a complete programme is not necessary for the patient to gain a significant beneficial effect.

Who Might Benefit?
Book-based therapy will not be suitable for everyone, but it is certainly appropriate for a proportion of those who consult their GP or other healthcare professionals with a psychological problem.

Bibliotherapy is ideally suited to a person who has a good level of literacy, who is highly motivated to work independently to tackle his or her own problem, and who is familiar with the process of following a structured ‘recipe’ in a book (as in a cookbook or DIY book). For those who are able to make use of bibliotherapy, the books highlight a problem-solving approach to recovery andemphasise the potential of self-management. The person becomes knowledgeable about their difficulty and is encouraged to engage in self-monitoring, self-assessment and guided self-treatment. The emphasis is on the individual’s active involvement and empowerment in recovery instead of, or in conjunction with, medication to deal with the problem.

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Advantages of Bibliotherapy
Studies have demonstrated that the use of high quality bibliotherapy books can produce therapeutic outcomes comparable to those of drug therapy or psychotherapy. And because the costs of bibliotherapy are minimal, the cost-effectiveness of this form of therapy can be extremely high. An optimal strategy in treating certain types of mild to moderate psychological problems (in line with NICE guidelines) may be to begin with bibliotherapy and then to move on to medication or psychotherapy if the bibliotherapy fails to produce the desired results.

Several possible advantages of bibliotherapy over the use of medication may include:

  • higher patient acceptability       
  • a greater sense of self-management, self-control and personal achievement
  • higher adherence rates
  • more immediate effects than some medications (particularly antidepressants)
  • no rebound effect when treatment comes to an end
  • a tendency to continued improvement over time
  • lower relapse rates
  • long-term additional benefits (resulting from skills and insights gained)
  • no appreciable adverse side effects
  • no adverse reaction with medication or other forms of treatment
  • no significant contraindications
  • no danger of an overdose
  • safe in pregnancy

(Frude, 2004a)

Beneficial effects of bibliotherapy may be experienced as soon as the person begins reading a book, and the immediacy of this form of intervention contrasts with the delayed action of some medication and the considerable waiting time that may be involved in referrals to professional and voluntary services. Indeed, one important use of bibliotherapy is as an interim (as well as an additional) intervention for those receiving, or waiting to receive, other forms of treatment for their problems. The evidence suggests that bibliotherapy is likely to provide substantial relief, and may render subsequent treatment more effective. Indeed, in some cases further treatment might no longer be necessary.

Limitations of Bibliotherapy
Not all self-help books are useful and there are materials of varying quality in existence; the book needs to be of high quality to be effective.

Bibliotherapy requires a good standard of literacy and a comfort with reading. If advised for someone who is not open to it, it might lead to negative self-attributions, hopelessness and a decrease in further help-seeking behaviour (Kuyken, 2004).

Many of the books on bibliotherapy lists are only available in English and they are not available in large-print format.

Important Caveat: In order to mitigate some of these limitations those recommending bibliotherapy should ensure that the book is of high quality (e.g. chosen from an established list) and that bibliotherapy is acceptable to the individual.

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