Psychological well-being, improved self-confidence, and social capacity: bibliotherapy from a user perspective

ABSTRACT

This article in the field of bibliotherapy investigates how participation in a reading circle can contribute to psychological well-being in people with mental illness such as long-term depression and anxiety. The perspective employed is user-centered and focused on the users’ statements about their health and well-being. Through a combination of quantitative and qualitative methods, the study which the article is based on, showed that participants had short-term improved psychological well-being after participating in a guided reading circle. Interviews clarified that their social well-being had been positively influenced in various ways, including greater self-confidence and increased social interaction. The choice of – short stories and poetry – was significant to the positive results achieved by the participants, as were the discussions about the texts, the presence of a circle leader with good leadership qualities, and the opportunity to be included in a group whose membership remained constant throughout the series of sessions.

KEYWORDS:

• Creative bibliotherapy
• fiction
• psychological illness
• psychological well-being
• user-centered bibliotherapy

Bibliotherapy, the use of literature to promote mental health, has only recently attained significance in Sweden. As late as 2010 there were very few bibliotherapeutic activities at Swedish libraries and health care centers, but reading circles for people on sick leave and those with relatively mild psychological illnesses are more common in 2017. Swedish research on the impact of reading on health and well-being is still in its early stages; a doctoral thesis by Eriksson (2006) and books and articles by Persson (2012), Pettersson (2008), Pettersson (2014, 2016), and Mårtensson and Andersson (2015) are the first significant Swedish contributions to the field.

Although bibliotherapy has been quite well researched internationally, the aim has usually been to determine whether it is an effective, evidence-based treatment for psychological illness. British scholar Elizabeth Brewster (2011, 2016) refers to many recent studies on self-help bibliotherapy, but her observations may also be relevant to research into “creative” bibliotherapy using fiction (Glavin & Montgomery, 2017). The dominant research perspective has focused on the individuals and institutions that offer various forms of bibliotherapy, rather than on those who experience bibliotherapy (Brewster, 2011, 2016). Like one of her predecessor, American researcher Cohen (1992), Brewster attempts in her doctoral thesis to change that perspective and focus on users’ experiences of the method and its effects on their health and well-being. I have a similar ambition in this study. Four people who suffered from long-term anxiety and depression took part in a reading circle during the fall of 2015 at an Activities House in Gothenburg (Sweden’s second largest city) and were interviewed about their experiences and their thoughts on having participated in the circle.¹

I am interested in what the reading circle meant to the participants and whether they believed it influenced their psychological well-being. Earlier research found that reading circles have a “significant potential to increase feelings of well-being in participants,” but concrete examples of how and how much psychological well-being was influenced were not provided (Hodge, Robinson, & Davis, 2007). My ambition with this study was to find more concrete and profound answers to these questions. In research reports, it is not unusual to find perfunctory assumptions that “quality” literature – classics and poetry – are preferable in bibliotherapy (Reagan & Page, 2008; Shechtman, 2009). A critical overview has shown that such assumptions are generally not based on empirical studies, but appear rather to reflect researchers’ own attitudes (Pettersson, 2014). Even in this regard, the study applies a user-based perspective’ to explore which types of literature had the best bibliotherapeutic effects. Thus, the study develops one of the research directions that Brewster (2011) indicated as significant for future research. It is also important that participants’ responses be seen in relation to their previous reading habits. To achieve as broad an understanding as possible, I consider both the literature read by the participants in preparation for and within the circle sessions and their reading outside of that context.

Material and method

The reading circle did not have an explicitly stated bibliotherapeutic goal. The participants signed up voluntarily as private individuals, not as patients. However, because the circle was arranged with individuals with psychological illnesses in mind, it qualifies as bibliotherapeutic (compare Hodge et al., 2007). The Activities House markets itself as a support for people who suffer from psychological illness and wish to return to work or studies. The House’s program is largely composed of various types of study circles (http://goteborg.se/wps/portal/enhetssida/aktivitetshus-centrum/ 2017-06-09).

The reading circle met for two hours once a week for 12 weeks from September through December 2015. The literature selected by the circle leader, who had several years’ experience leading study circles at the Activities House, consisted of a collection of short stories (Fler nobeller [More Nobleists], 2012) by Nobel Prize winners in literature and several poems by Swedish poet and Nobel Prize winner Tomas Tranströmer, Swedish poet Karin Boye, and Finnish-Swedish poet Edith Södergran. The participants read a short story and one or more poems in preparation for each circle session. Some of the poems selected were read aloud at the sessions by the leader and the participants.

Seven participants attended the first session, and five of those attended every session. Those five were invited to be interviewed about their experiences of the reading circle and all agreed. One, however, never attended the interview appointments. Therefore, the qualitative material for this study is drawn from four in-depth interviews.²

A questionnaire was also used to more fully reach the goals of the study and gather quantitative data. The questionnaire was based on the SF 12 scale, which measures physical and psychological well-being over time. Because the study focuses on the participants’ psychological well-being, the questionnaire was modified to exclude five questions on physical health. The seven remaining questions were retained in their original formulations. The participants filled in the questionnaire twice: once after the second session and once after the twelfth (final) session. They were informed at these sessions that their participation in the study was voluntary and that they were free to withdraw at any time.

The individual semi-structured interviews, conducted after the last reading circle session, were based on a question guide with several specific themes such as reading habits, literary preferences, the significance of the reading circle, and the participants’ psychological well-being. All themes were addressed in each interview. The interviews were conducted in a separate room at the Activities House Center to provide participants a familiar environment in which they would feel safe and comfortable. Each informant was interviewed once. The interviews were recorded on a dictaphone and transcribed. All data were then secured as confidential. The names appearing in the analysis – Alexandra, Boel, Mikael, and Lena – are fictitious. The name of the circle leader, Arvid, is also fictitious.

Various significant units of meaning were identified in the informants’ responses. These units were then used as a basis for the classifying the responses into the following comprehensive categories: reading habits and literary choices during leisure time, function of leisure time reading, significance of the reading circle, and psychological well-being. The main body of the analysis addresses the last two categories with appropriate sub-headings. The responses relating to reading habits, literary choices during leisure time, and the function of leisure time reading are presented first to provide an explanatory background for the informants’ participation in the reading circle. In the results section of the study, the results, analysis, and discussion are interwoven to avoid redundancy.

Results

Reading habits and literary choices during leisure time

Researchers have frequently discussed the relationship between reading habits and the results of bibliotherapy. Brewster and Suzanne Hodge report on studies in which bibliotherapy has shown good results for people with wide differences in reading experience (Brewster, 2011; Hodge et al., 2007). Pim Cuijpers, however, who has conducted considerable research on bibliotherapy, maintains that bibliotherapy is more successful for participants who are motivated and have significant reading experience (Cuijpers, 1997). Since conclusions about reading habits and their significance in results for bibliotherapy clearly diverge, this is an area in need of further investigation.

All the informants in this study were interested in leisure-time reading and can be described as relatively frequent or frequent readers. All claimed to have read a lot in certain periods of their lives, but between those periods to have read less. In all the cases studied, these reading patterns appear to correlate with health-related issues, especially the ability to concentrate. It is clear, then, that reading requires people to be able to concentrate and gather their thoughts. This conclusion supports previous research on bibliotherapy showing that reading is a difficult activity for those with illness-related symptoms such as fatigue and difficulty with concentration (Brewster, 2011; Pettersson, 2016). Nevertheless, the informants in this study clearly valued reading and considered it to be very important in their lives. Lena said, “without reading I couldn’t exist,” and Alexandra explained, “I don’t pull down my bookcases, since some things there are dear to me.”

The types of literature chosen by the informants for leisure-time reading were mixed, with a preference for contemporary novels, classics, modern classics, and poetry. Among the writers mentioned in the interviews are Charles Baudelaire, Albert Camus, Romain Gary, Jean Paul Sartre, Gustaf Fröding, Ulla Isaksson, Henning Mankell, and Harry Martinsson. The question of the informants’ taste in literature and its relationship to the literature used in the circle is discussed under the heading “Literature in the circle.”

The function of leisure-time reading

The most significant functions of leisure-time reading in the lives of the informants can be categorized as informational, escapist, social, perspective-creational, esthetic, and therapeutic. The first three of these (informational, escapist, and social) are directly comparable to three of the four themes Brewster’s participants (2011) used to improve or maintain their mental health. Some of Brewster’s informants who read for escapist reasons reread books. Of the participants in this study, Mikael reread books and certain sections of novels more than the others and his esthetic enjoyment of these had a positive effect on his well-being. It is interesting to note that the therapeutic aspect appeared as a function on its own in my material. Lena reported that reading could have a curative function for her, and Boel described how she reads “to get myself – my motor – going.” Reading as a pathway to new perspectives, finally, has similar results to those sought in psychoanalytically influenced bibliotherapy: recognition and insight (Brewster, 2011; Cohen, 1992; McCarty-Hynes & Hynes-Berry, 1986; Rubin, 1978; Shrodes, 1949). That tradition has long been dominant in bibliotherapy. The participants in this study also stressed thoughts and feelings usually viewed in traditional bibliotherapy as insights, and they related absorbing the realities in the texts and seeing themselves in contexts larger than their own lives.

Significance of the reading circle

All participants perceived their participation in the reading circle as positive influence on their psychological well-being. They emphasized three particular aspects of the circle: (1) the choice of the literature itself, (2) the circle activity, and (3) the opportunities the circle offered for social interaction.

The literature in the circle

All participants expressed their appreciation of the literature read during and in preparation for the circle sessions. Mikael was particularly affected by Saul Bellow’s short story “A Father-To-Be” and he described the significance this piece held for him in detail. Lena specifically said Tranströmer’s poems and her having “time for more ‘quality’ literature” were important, and Boel said it was “good to read the texts of Nobel Prize winners.” Lena’s and Boel’s responses indicate a preference for quality literature among the participants, a preference at least partially explained by their similar tastes in the literature and authors they read on their own. However, a considerable amount of data in the interviews calls into question the assumption that the specific content or quality of the literature determines the therapeutic effect of the circle. Most participants emphasized the importance of the short length of the texts, which made it possible to read through them before each session. Mikael said that having the time to read through the texts before each gathering was a positive aspect of the circle. Alexandra explained that in recent years she had taken to reading short stories in her leisure time as well, and that reading an entire piece before falling asleep at night had had a positive effect on her sleep and therefore on her general health. Boel continually repeated her positive opinion of the short texts used in the reading circle. The length of the texts appears to be at least as significant as their content. This conclusion must, however, be understood in light of the participants’ psychological illness.

Difficulty with concentration resulting from the participants’ illness contributed to their inability to read much material at any given time. Because the literature circle met frequently (once a week), it seemed important to keep the texts short, especially since the participants clearly expressed satisfaction at being able to read entire texts before the sessions. This makes it clear that circle organizers should consider participants’ illnesses and their possible consequences when planning both the frequency of the circle sessions and the literature for bibliotherapy. This has not been discussed at any length in previous research.

Another aspect that emerged in the interviews, which raised the question of whether literary quality should be the most important criterion for reading material in bibliotherapy, was the opportunity the reading circle offered participants to read literature they had not previously read. In a study by Hodge, well-read individuals said that an advantage of bibliotherapy was that it widened their literary horizons (Hodge et al., 2007). Several studies have shown that randomly selected literature functions just as well as carefully selected material in bibliotherapeutic activities. Brewster points out that several of her informants reported that the act of reading itself was more important than the specific works read in helping them deal with their psychological problems (Brewster, 2011). It would appear that literary quality is less important than literary variation and the act of reading itself.

The circle sessions

The second category in the study focuses on the circle sessions themselves. This category can be further divided into three subtopics: the literary discussions, significance of the circle leader, and the significance of the reading circle in relation to other circle activities.

The literary discussions

Interestingly, the aspect of the literary discussions most appreciated by the participants was not the opportunity to present their own interpretations of the texts, but rather to enrich their own understanding of the literature through hearing the others’ interpretations. This attitude was expressed in all of the interviews, and is perhaps best summarized in the following quotation:

And the advantage with the circle is that you get more ideas since the people around the table add to the discussion and you get another, better understanding of the text since there are a number of us reasoning about it and you can build on each other’s ideas.

Here we see that literary interpretation becomes a collective act in which other participantś perspectives deepen the individual’s understanding of the text; participants dare to take their thinking to new levels when they “build on each other’s ideas.” Previous research results have been similar. One of the functions of the bibliotherapeutic reading circle noted by Brewster (2011) is that of an intermediary for opinions and experiences. Josie Billington and Jude Robinson have observed how participants’ self-confidence increases as they dare to engage in bibliotherapy group discussions (Billington, Dowrick, Hamer, Robinson, & Williams, 2010; Robinson, 2008). For one of my informants, this increased self-confidence through group discussion was extremely important; she found a form of confirmation that her thoughts and interpretations were reasonable and that she need not, as she put it, “feel that I’m the dumbest in the head”.

The circle leader

The importance of the circle leader to the results of bibliotherapy has been stated often in previous research (Billington et al., 2010; Brewster, 2011), and this study confirms that conclusion. All participants declared the importance of circle leader Arvid to the reading circle activity and described him, without exception, in positive terms. The qualities that the participants particularly appreciated were his ability to lead the circle, to shift the focus of attention between different speakers, to always come well-prepared for the sessions, to convey his own keen interested in literature, and to speak excellent Swedish. Participants emphasized, above all, aspects relating to literature and leadership. Alexandra and Mikael believed that their results and positive experience of the circle activity depended partly on Arvid’s leadership. Alexandra believed that Arvid’s experience in conducting many previous study circles at the Activities House and his good reputation there may well have contributed to the good number of participants in the circle and the fact that many of them completed it. Mikael too considered Arvid’s long experience as a circle leader at the Activities House significant, but he also emphasized that Arvid is extremely well-read and has the ability to enthuse the participants.

The significance of the reading circle in relation to other circle activities

To better comprehend the significance of the reading circle for the participants, it is fruitful to analyze how they discuss and value it in relation to other circles they have experienced. All study participants reported having taken part in two other circle activities such as current events, painting, needlework, current political debates, Italian, photography, and philosophical topics. Mikael said that the reading circle was undoubtedly the most important one for him. He is also the one who most clearly highlighted the significance of the literature itself and of the act of reading in the circle sessions. It is also plain that, in Mikael’s case, the literature and the reading were more significant to his life outside of the sessions than the other circle activities were, and that he felt this factor was specifically characteristic of the reading circle:

[The circle] that has had the most importance is surely the reading circle. / … / That one I’ve taken home with me in another way than the others … since we read a short story before each time and all. So, I’ve stretched out at home and thought a lot about the text and all.

The reading circle apparently builds bridges between various life contexts and binds the circle experience and private life together in a meaningful unity.

Mikael, Alexandra, and Lena all point to another aspect that they consider unique to the literature circle as opposed to the other circle activities they have experienced. This is the discussion of the subject itself – in this case literature – as a given aspect of the activity. From this perspective, Mikael and Lena contrast the reading circle with the other circles, in which they maintain the activity took place at the Center without any discussion and without it affecting their daily lives or thoughts the way that the reading circle did. They both valued this aspect of the reading circle highly. Research on culture and health has shown that verbal reflection on cultural activity conducted during the activity itself improves that activity’s health-enhancing results (http://www.kulturradet.se/sv/verksamhet/Kultur-och-halsa/Kultur-i-varden/Ostergotland-Gott-exempel-2/, 2016-06-02). The importance of the reading circle to the participants was also shown by their all declaring a wish to continue their participation if the circle were offered the following term. Lena stated that she planned to continue her participation even if she happens not to have “much money left for tram coupons next year” and will have to choose between circle activities. Thus, she clearly showed how important she considered the reading circle.

Social interaction

The opportunity for social interaction provided by the reading circle is the third category that emerged from the interviews. All study participants were clear that it was important for their well-being to come into the social sphere and take part in social activities, and the reading circle was an important impetus. According to Alexandra, the quality of social interaction at the Activities House is much greater in study circles than in simply socializing with others in the open rooms. The sense of group identity provided by the circle was very significant to the participants. Mikael said, “I feel better if we can be a group.” For him, as for the other participants, the constancy of the circle was important, i.e. that the same individuals took part continuously. “It becomes a group feeling, a sense of us together, we learn to know each other in another way” said Alexandra, reflecting on her participation in the reading circle. This result is interesting when compared with results in British research in bibliotherapy. In Great Britain, where bibliotherapeutic reading circles have been organized in libraries and healthcare facilities for many years, open circles, in which participants may freely come and go, are a part of the offerings. Research done on those circles has judged this openness as a positive aspect of the activity, but has not reported on the users’ experiences of how it affects the sense of group identity and security within the group (Billington et al., 2010). This study shows that group constancy is important to the users, and that their views on this subject should be considered when determining the results of bibliotherapy. For most of my participants, the identity of the individual members of the group was unimportant. However, one of the participants considered it important that many people took part in the sessions, so that the sense of the circle could be maintained. This attitude further strengthens the significance of the group as such in this context.

Psychological well-being

The reading circle was apparently meaningful to the participants and taking part had a positive effect on their perception of their health and psychological well-being. But how had that occurred, and to what extent? The answers to the questionnaire did not give clear evidence of improvement in psychological well-being in all of the participants over the three months of the circle activity. One participant reported feeling somewhat better at the conclusion of the circle, another somewhat worse, and two felt about the same at the end as they had at the outset. The interview responses as a whole, however, do provide the questionnaire’s somewhat contradictory results with a more nuanced and detailed picture of the participants’ psychological well-being over the course of the circle. They show that participation in the circle provided a short-term better sense of well-being for all study participants. Mikael expressed a consciousness of improved well-being when he said, “I have felt better about leaving home to come here [to the reading circle],” and Alexandra described the reading circle’s effect as “to say uplifting would be an exaggeration, but something like that.” She also reported that reading alone could prevent a worsening of her well-being, but taking part in the reading circle could improve it. Both Alexandra and Mikael could estimate the range of psychological well-being they experienced after participating in the circle sessions. For both, it was a feeling lasting from an afternoon to a whole day. This duration is so limited that it does not surface in the questionnaire.

Lena compared the psychological well-being she felt from taking part in the reading circle to her feelings when participating in enjoyable activities: “instead of having a boring time you can actually feel better.” Her statement supports previous research on bibliotherapy that shows the significance of enjoyment to health and well-being (Pettersson, 2016). She added, “Even when the weather’s been bad, I’ve come here,” revealing that the reading circle had enough attraction for her to overcome her resistance to going outside in inclement weather.

The answers to one question in the questionnaire, however, about participants’ abilities to perform everyday activities and duties as usual during the circle sessions revealed a deeper and more lasting change. At the beginning of the study, two participants answered that they could perform activities of daily living as usual, but at the conclusion all of them answered positively. In this respect, a clear improvement in psychological well-being can be observed in two of the four participants. These answers were nuanced in the interviews, when participants gave many examples of activities they felt they were better able to perform because of their participation in the circle. These activities can be sorted into the three categories of reading, social activities, and daily chores.

Reading

All the participants experienced an increased desire to read and increased their reading as a result of participating in the reading circle. Because reading was a previous interest for all participants, taking part in the reading circle could be argued to have stimulated an existent but, for various reasons, dormant interest. Mikael was one of those who reported that, since joining the reading circle, he had begun reading more on his own than previously, and that it “has felt fantastically good to be able to read again.” Interestingly, both he and Alexandra became able to use literature occasionally as self-medication. Mikael reported that, on bad days, he could sometimes read himself to a temporarily higher level of well-being. Alexandra said that she could resort to reading to prevent her well-being from deteriorating. Lena and Boel also reported that their desire to read increased. Lena has now borrowed books by Nobel Prize winners from the library, and Boel has begun reading literary criticism.

Social activities

Billington and her research team studied whether psychological and social well-being can be increased and depression alleviated through reading. Increased social well-being, according to that study, involves increased self-confidence, increased self-esteem, diminished social isolation, an experience of increased social community, and improved communication skills (Billington et al., 2010).

The participants in my study exhibited most of the increased abilities and skills mentioned by Billington, and all participants decreased their social isolation by taking part in the reading circle sessions. Alexandra exemplified improved social well-being in terms of increased self-confidence and improved communication skills when she related that after participating in a session she can go home and do social chores she otherwise would avoid, such as making a telephone call. She also observes that “one social contact often leads to several more social contacts.” Mikael illustrated how the reading circle increased his social interactions when he reported that he can now talk about literature with his parents, who share his interest. Their common interest has generated further topics of conversation, a mutual exchange of literature recommendations, and strengthened relationships.

Daily chores

In addition to the activities and abilities described thus far, others of a more practical nature also seem to have resulted from participation in the literature circle. Alexandra, for example, said that she could wash the dishes “without hesitation” after a circle session, and added that household chores in general were just not as demanding as they were before the reading circle. Lena said that although she would, of course, do her daily chores whether or not she took part in the circle, she perhaps did them more happily and with more energy after the circle sessions.

Summary

This study showed that participants in the reading circle had short-term improvement in their psychological well-being. It also clarified, through the interviews, that participants had increased self-confidence and became more socially active. The aspects of the reading circle activity that participants experienced as positive and seem to have led to good results were (1) the use of short fictional texts that participants could read completely between circle sessions, (2) the exchange of experiences and thoughts about the literature in the reading circle discussions, (3) the presence of a circle leader with good leadership qualities and a strong knowledge of literature, and (4) the opportunity to be included in a stable group of participants from session to session.

Because this is a small study with no control group with which to compare results, one cannot draw particularly far-reaching conclusions. However, it does underline the need to combine quantitative and qualitative data to reach a more nuanced and correct reading of the results. Without the in-depth interviews included in this study, the participants’ improved short-term psychological well-being, increased self-confidence, and improved social skills would not have been noted, and the results would consequently have been misleading.

This study also contributes to the generation of new knowledge in research on bibliotherapy by showing the need to consider the relationships between possible illness, symptoms of illness, and the frequency of the reading circle when choosing literary texts for the most favorable results of bibliotherapy as possible.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1 The reading circle was arranged by Folkuniversitetet (The Peoples’ University) in cooperation with Aktivitetscentrum (Activities Center), Kultur i Väst (Culture in the West), and Göteborgs Litteraturhus (House of Literature in Gothenburg).

2 Three of the four respondents were women and one was a man. Their ages varied from 45 to 77 years. They were all unmarried and living alone at the time of the interviews. Three lived in Gothenburg and one in Mölndal, a municipality bordering on Gothenburg. All suffered from psychological illness expressed mainly through anxiety and depression. Two of the informants were retired and the other two were on early retirement. All four had previous occupations of various stability before retirement. The occupations represented were research assistant, national administrator, psychiatric nurse’s assistant, office assistant, teacher, and warehouse worker.