The Effectiveness of Bibliotherapy Intervention on Patients with Depression
by Faezeh Tawafi
In recent years, bibliotherapy has become more common, as it is considered an effective treatment for depression that provides fewer side-effects with long-lasting results. Bibliotherapy can be used to replace other treatment methods, such as anti-depression drugs and psychological counseling. This paper has used both primary and secondary research using online journals and conducting an interview. Bibliotherapy is an effective alternative to antidepressants as it carries the same results as the drugs but with fewer side-effects. Some may consider bibliotherapy better than psychological counseling because it is more private, costs less, and is more available to the patients. In addition, it also provides relaxation, which is not the main focus of treatment but a positive side effect. By analyzing the collected information, it was found that bibliotherapy can be combined with other treatment methods to get the most outcomes. However, bibliotherapy has some drawbacks that limit its usage for some of the patients, and one of the main ones is that bibliotherapy works better with patients who are passionate about reading.
Keywords: bibliotherapy, depression, books, antidepressants, psychological counseling
The Effectiveness of Bibliotherapy Intervention on Patients with Depression
Today, 300 million people in the world suffer from depression (Morin, 2018). Depressed people are burdened continuously with emotional distress. They tend to search for the most effective treatment that has the least harmful effects on them. Depression has several methods of treatment, and each of them has its advantages and disadvantages. According to Dr. Koenig (n.d.), combining antidepressant drugs and psychotherapy is the most common treatment for depression. One of these methods is bibliotherapy, which is the use of literature to treat psychological problems. It roots back to 1914 when it was used during World War I, where librarians were stationed at military hospitals to provide books to patients with issues, including mental problems (Mahoney, 2019). Bibliotherapy is effective and should be marketed more because it is a better alternative to antidepressants, it is better than counseling sessions in terms of cost, privacy, and availability, and it has additional benefits such as obtaining relaxation.
How is Bibliotherapy Implemented?
Bibliotherapy attempts to change patients' thoughts and feelings; therefore, it uses behavioral treatment instead of physical treatment for healing depression. Bibliotherapy is performed through Cognitive Behavioral Therapy (CBT). According to Jacobs (2009), CBT is determined psychotherapy or talk-therapy treatment that targets to improve mental health. CBT focuses on altering nonessential cognitive behaviors to enhance emotions. CBT can be used alone or in combination with medications. Bibliotherapy, which is a subcategory of CBT, is used when a patient has a regular therapy session with their therapist to break down the problem into thoughts, feelings, and actions and depending on the therapist's diagnosis, a book or a literature-related task will be suggested to the patient. Jacobs further discussed that these books could be in the form of self-help books, novels, poetry, or writing a literature piece. Bibliotherapy can be done by patients themselves, with a therapist, or in a group. A successful bibliotherapy session involves professionals who supervise, train, and guide intervention.
Is Bibliotherapy as Effective as Antidepressants?
Medications have always been an effective method for treating depression and other psychological problems. Antidepressants affect a patient by balancing out the chemicals in their brains. These chemicals target the patient's mood, which reduces the symptoms of depression in them. In the case that an antidepressant does not function effectively, patients may use other medications of the same type or try changing the dosage (Ballinger & Feely, 1983). The understanding of the effectiveness of two types of treatments, CBT and antidepressant, is yet advancing, and specialists are investigating to get more understanding about these treatments. A systematic study of 10,000 patients had discovered that both CBT and antidepressants were equally effective (Khan et al., 2012). Realizing that both CBT and antidepressants have the same performance requires further research to compare them with more precision in terms of their side-effects.
Side Effects of Anti-depression Drugs
The antidepressants prescribed by specialists are well-tested; however, it might cause sleeping disorders, agitation, and sexual dysfunction in the long term. Also, using a combination of antidepressants with other medications increases their side effects (Dalfen & Stewart, 2001). Using antidepressants with other drugs is very common, especially among older patients, because as they age, they face multiple health problems that require them to use multiple drugs. That is why the risks associated with consuming these drugs increases. Fava et al. (2006) conducted a study on a sample of 117 depressed patients who were asked to use antidepressant drugs. It was found that more than 30% of the participants reported mental side-effects such as forgetfulness and distraction. Also, more than 40% of the patients reported physical side effects such as sleepiness and fatigue. Given the risks associated with antidepressants, it is essential to consider whether other non-pharmacological treatments could be used to give patients and therapists an efficient option with fewer side effects.
Side Effects of Bibliotherapy
Similarly, bibliotherapy carries a few side-effects that do not seem critical, but it might cause severe problems in the long-term. These side effects happen because the books recommended during CBT are not written for each patient specifically; therefore, there might be some that do not match the patient’s case. The common side effects are inclusive of anxiety, anger, stress, and personality disorder (Jarrett, 2018). Mostly, these effects appear if the patients are not fully able to engage themselves with the story. According to Rubin (1979), the patients engage themselves with a character in a book or react to a situation described in the story. Due to the objective nature that literature provides in this scenario, patients can analyze and discuss the issue by themselves or a therapist in a non-threatening and safe environment. The engagement process fails if the patient has a lack of understanding of the situation, which may result in side-effects. Therefore, it would be a waste of time for the patient because it would focus on a problem that does not exist; meanwhile, the real problem is deteriorating, and in extreme cases, it could cause personality disorder. Analyzing the information gathered shows that the side effects of bibliotherapy are less destructive than those of antidepressants. According to Naylor et al. (2010), a treatment method that has fewer side-effects has more benefits because for the same result being obtained, less risk is being involved. They further proved that in the long term, bibliotherapy results last longer than medications’ results because chemical reactions are more in favor of changing their state than mental behaviors. Subsequently, bibliotherapy prescriptions can be considered as a strong alternative treatment to drug prescriptions.
How Do Literary Texts Work in Bibliotherapy?
Knowing that bibliotherapy is considered to be as effective as antidepressants, a closer look should be taken on how the books are particularly used. When bibliotherapy needs to be used, therapists analyze patients' behavior to recommend a book according to their needs. However, for depression, they suggest books that change the patients' perception of the world, cheer them up, and to let them think optimistically. The Feeling Good Handbook, written by Dr. David Burns, is one of the most effective, top recommended books to patients diagnosed with depression. Burns (1999) uses a simple yet straightforward language to discuss a depressed patient's thought process. He mentions:
The secret of successful treatment is not to become a perfect, shining star or to learn to be in complete control of your feelings. These strategies are doomed to failure. In contrast, when you accept yourself as an imperfect but eminently lovable human being, and you stop fighting your emotions so strenuously, your fear will often lose its grip over you (p. 127).
Depressed patients lack believing in themselves as they think that becoming perfect is impossible. These thoughts make them feel disappointed in themselves and, in the long-term, turns into a severe depression, pessimism, and sadness. According to Bohning (1981), the treatment process of bibliotherapy consists of three phases: identification, catharsis, and insight. Firstly, identification is when the author defines a situation that the reader could match their life with. Secondly, catharsis is when the reader becomes emotionally involved with the character and follows how it goes through a problem. The last phase is insight, which is when the readers understand their problem and begin to apply the character’s solution to their own life.
How is Bibliotherapy Better than Psychological Counseling?
Another positive point that shows the effectiveness of bibliotherapy is the advantages that books have over other treatment methods. These advantages include privacy, cost, and availability. As mentioned earlier, books are one way of implementing CBT through bibliotherapy on patients with depression. One of the common types of books used is self-help books that aim to instruct the reader to solve their personal problems. Self-help books affect the reader’s mind by controlling the effort they put on reading, such as the time they allocate on reading the books. Self-help books can improve self-awareness, self-satisfaction, and life-performance (Bergsma, 2008). Moreover, according to Quilliam (2005), self-help books carry plenty of positive assets that are helpful throughout the treatment process, and one of the main ones is the privacy associated with books. They are the most convenient treatment method for patients who are embarrassed or do not like to share their personal problems. Also, books help the patients by showing their problems as less personal, which in turn makes them feel more comfortable about their insecurities. These books also improve the sense of trust in the patients, which overall leads to an increase in their self-esteem and life satisfaction (Quilliam, 2005). Indeed, by reading these books, the reader’s self-expectation increases, thereby to meet their higher standards, it requires themselves to put effort into achieving their aims. All in all, books allow patients to solve their issues by themselves without anyone else being involved.
Similarly, cost and availability are two other significant factors that give dominance to bibliotherapy. Considering the costs, the only expense for a patient who is under bibliotherapy is buying the book. The book prices are relatively low, making it affordable to most people (Bergsma, 2008). According to data provided by Statista, the average price of books in the United Kingdom in 2015 was $8.66 (The Bookseller, 2019). On the other hand, the average price of psychology counseling varies from $39.34 to $157.34 per session (“How Much Does Therapy Cost?”, 2018). These prices show that books have a notable superiority in costs compared to counseling with a psychologist. Moreover, availability is another important factor that gives books more accessibility. Bergsma (2008) states that there is a real abundance of books in every bookstore. There are plenty of books for every mental health problem suitable based on each person’s preferences. Also, books can be used anytime and anywhere; they can be read during lunch or at night before sleep. By contrast, an average psychotherapist has 20 sessions of treatment per week, and taking the number of patients into account, the process of visiting a therapist becomes complicated, which reduces the availability (Imel et al., 2015). Considering the benefits correlated with availability, it makes the use of books more accessible and convenient.
Real-Life Case for Bibliotherapy
An article written by Floyd (2003) reported a successful bibliotherapy case which resulted in being more effective than a counseling session. Sarah was a 65-year-old great grandmother and wife. Her husband suffered from heart disease at age 39, but later, he recovered fully. However, Sarah was aware of her husband's situation (before the recovery) and feared that her children might grow up without a father. Therefore, she decided to do all the work by herself so that her children can spend most of their time with their father. Consequently, the family members took her work for granted, and her children wanted to spend time with their father. Over the years, Sarah resented how her family treated her, and she experienced a major depressive disorder. In accordance with CBT, the first session was about diagnosing the problem, identifying goals, and revising the treatment process. Sarah attended multiple therapy sessions and tried to follow the therapist's talks and suggestions, such as doing fun activities or getting involved in society. At this point, her family did not expect her to carry on as usual because they were worried about her. Nevertheless, this situation lasted only for two weeks as her family requested too much help. At this point, the counseling session was likely to fail. According to the therapist, the situation was getting worse, and there was not enough time per session to instruct her adequately to overcome depression. Besides, Sarah's schedule did not allow her to attend more sessions. Therefore, the therapist used bibliotherapy as a last resort by recommending a book that would fit her needs. Sarah's willingness to use bibliotherapy allowed her to concentrate more on the skills she should improve, such as caring more for herself. In Sarah's case, bibliotherapy made her find a balance between work and fun activities. Indeed, bibliotherapy was more effective than counseling sessions because of her limited time and lack of availability.
Additional Benefits of Bibliotherapy
The third argument for bibliotherapy is about the additional benefits that patients may gain, which might not have been one of the purposes of the treatment. One such benefit is obtaining relaxation from the process of bibliotherapy itself. Bibliotherapy is not limited to reading books or other literature-related activities (e.g., journaling or biographical writings); it also includes discussions about texts. In some cases, the task of maintaining a diary i.e., journaling, which is the act of writing a journal or diary and a common method of bibliotherapy, is used to allow patients to engage them with the writing process (Lohmann, n.d.). It helps patients gain additional benefits embedded within the treatment process, such as relaxation as stated above. Writing a diary or journaling targets more than one specific mental issue and allows patients to present their thoughts on paper to de-stress, and after a while, this process leads to mental healing (Utley & Garza, 2011).
Journaling as a Form of Bibliotherapy
Journaling through CBT is the act of allowing the patient to write and process the writing task as therapy. Journaling regards that writing feelings gradually help to treat emotional conflicts (Woolston, 2000). Usually, journaling is administered by a therapist through counseling sessions in a way that the therapist reads the patients' journals and helps them by suggesting ideas to improve. Journaling engages patients with an activity that results in higher self-awareness and growth (Hubbs & Brand, 2005). According to Dr. Mehvash Ali, director of the Academic Support Centre and major academic advisor at the American University of Sharjah, journaling as a treatment method provides an opportunity for patients to uncover their inner feelings and identify themselves (p.c., April 9, 2019). Furthermore, she stated that journaling opens new doors for depressed patients to communicate their thoughts and ideas, which, in the long term, helps treat mental health issues. Dr. Ali suggested journaling mostly for shy and non-voluntary patients. It could be used as a precursor to the counseling sessions as the patients develop comfort before developing a deeper connection with the therapist.
Notably, a significant benefit associated with journaling is obtaining relaxation as discussed earlier. Relaxation can help patients overcome daily stress and manage responsibilities and tasks with less pressure on them. Moreover, practicing relaxation techniques has other benefits for human health, such as lowering blood pressure, improving digestion, maintaining healthy blood sugar levels, and reducing muscle tension (Mercola, 2015).
In conclusion, bibliotherapy is considered a behavioral treatment method that can be combined with other methods to acquire the most beneficial outcome. Considering that bibliotherapy still has some downsides, it is still regarded as one of the least harmful treatment methods. Bibliotherapy has a few limitations when it comes to implementing it for every case; for instance, it works better for patients who are avid for reading (Floyd, 2003). This limits the use of bibliotherapy, but it still can be used as an effective treatment method for depression as it is a better alternative to drugs, it is better than counseling sessions in terms of privacy, cost, and availability and, it has additional benefits such as relaxation.
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