Creative and self-help bibliotherapy
The perennial lack of resources for prevention and treatment of mental illnesses including eating disorders [1], combined with their biopsychosocial complexity, make ‘bibliotherapy’ – the reading of books, typically self-help books, for therapeutic purposes – an attractive option. Recommending that a patient read a particular book, or recommending that (s)he read more (or less) in general, has long been part of medical practice [2], but in recent years bibliotherapeutic approaches have begun to be formalised, and in the UK, for example, they are now commonly included in public health interventions [3], national healthcare trust provision [4], and clinical guidelines [5].
The efficacy of ‘self-help bibliotherapy’ (bibliotherapy using self-help manuals) has a growing evidence base in the treatment of eating disorders. A 2009 meta-analysis [6] found ‘promising’ effects for ‘first-step’ care in a range of studies, with slightly greater efficacy for guided self-help (supported by a nonprofessional) than for unguided or ‘pure’ self-help, but with high variability across the different eating disorders. These results were extended in 2013 with a further review noting an expanded evidence base for guided self-help in tackling behavioural symptoms of bulimia and binge-eating disorder [7]. A 2006 review [8] comparing pure and (professionally or nonprofessionally) guided self-help with other or no treatment found comparable effects to those achieved by other psychological therapies on bingeing and purging, other eating-disorder symptoms, interpersonal functioning, depression, and treatment dropout. This included moderate improvement for psychiatric symptoms and interpersonal functioning but no difference from waiting list on key behavioural criteria, and no overall difference between the two self-help types. However, most of the studies included in this review were small and probably underpowered.
All existing studies of bibliotherapy for eating disorders use self-help books based on the principles and methods of cognitive behavioural therapy (CBT), and all treat them as examples of CBT rather than as books: no linguistic details are ever mentioned, and even the titles tend to be buried in the references. Some consideration is given to the pros and cons of self-help, like lowering the barriers to seeking help, or working at one’s own pace, or conversely feeling a personal failure if recovery is not achieved [8,9,10], but these concern what it means to work alone as opposed to with a therapist, rather than to work with a specific text. Paradoxically, then, although the purpose of these trials is to assess the efficacy of self-help books, often in comparison with other therapeutic interventions, the books being used are to a large extent treated tacitly as neutral substitutes for a therapist: the distinct constraints, possibilities, and effects of their medium (written language) have not been subject to investigation in their own right. As Perkins and colleagues remark at the end of their review, more research is needed to establish what the ‘“active” ingredients in self-help treatment are’ [8, p.10].
To give one example of the kind of textual complexity that needs investigating: the self-help book used far more often than any other in the clinical research, Christopher Fairburn’s (1995) Overcoming Binge Eating [11], incorporates numerous (presumably fictional) vignettes from the perspective of a hypothetical eating-disorder sufferer (even including a ‘handwritten’ food diary and a supermarket receipt) alongside the factual information and behavioural and reflective tasks for the reader to complete. Yet the potential effects of this combination of textual features have been ignored in favour of a conception of the self-help manual in which written language is a transparent vehicle for delivery of CBT, not a richly selective and associative medium capable of generating a variety of specific (wanted and unwanted) responses in readers. If better understanding of the ‘active ingredients’ of textually mediated therapy is what we seek, research on the many forms of language use that make up the text in question will be crucial, and should not assume from the outset any hard dividing lines within generic or stylistic dimensions such as factual–fictional, narrative–discursive, literal–figurative, or concrete–abstract.
By definition, this point holds for any kind of text that may be enlisted therapeutically, whether ‘self-help’ or any other genre. Yet in part perhaps thanks to this neglect of the psychological capacities of language itself, genres which do not purport to deliver a direct alternative to face-to-face therapy have barely been researched in any context – and for eating disorders not at all. Rather more is known about the therapeutic practice of creative writing – variously known as poetry therapy, expressive writing, and therapeutic writing – for eating disorders, and this evidence is the subject of a recent review [12]. But here, I restrict my focus to the underexplored realm of reading. Although related processes of interpretation and sense-making are active in both, those involved in reading are both more prevalent as casual everyday activities than those of expressive writing; they are also structured by often extended engagement with a complex textual prompt, but often do not result in explicit interpretive ‘end products’ (beyond telling a friend or reflecting privately on what one thought of the book, for example). Hence reading and writing merit independent consideration. These features – the frequency of reading as an everyday habit and the qualities of specifically textually cued interpretation – will be explored further in what follows.
Despite its scarcity, what evidence there is for reading beyond self-help is promising. The most common term for the therapeutic use of books other than self-help is ‘creative bibliotherapy’. This tends to involve (guided or unguided) individual engagement with what we might call ‘literary’ works – prose fiction, poetry – but sometimes also includes film-viewing. Although the term arguably lacks transparency on first encounter, the findings of this study suggest that precisely its open-endedness – in particular not delimiting in advance the range of textual genres – is a significant advantage. A rare systematic review of causal evidence for creative bibliotherapy in the context of children’s behavioural development [13] found a small to moderate effect, and a more recent review for post-traumatic stress disorder [14] found promising trends in some low-quality and qualitative studies, though the authors located no high-quality controlled trials. Related work on reading groups rather than individually tailored reading has included observational qualitative studies finding marked benefits of engagement with novels, stories, plays, and poems for populations such as women prisoners [15] and people with depression [16]. No systematic evidence specifically for eating disorders exists at present, however.
Overall, as psychiatrist Jonathan Detrixhe puts it, ‘Unfortunately, thus far, the mere belief in fiction’s important place in the therapy room is held in higher esteem than the need to rigorously research the phenomenon’ [2, pp.60–61]. This holds both for the presence or absence of efficacy and for its possible mechanisms. Longstanding theories of creative-bibliotherapeutic change [17,18,19] tend to propose a process of identification (with the character in the text), insight (into the reality of the illness), and problem-solving [2], sometimes mediated by some kind of emotional catharsis. But these theories persist despite a paucity of supporting evidence beyond some case-study reports written by students [20] and very small-scale patient self-report data [18]. A partial exception is Zipora Shechtman’s [21] model, which involves exploring the problem, gaining insight, and committing to change, and which has some empirical support. But the model lacks theoretical precision as regards the materials used (stories, poems, and films are treated as equivalent) and the specific mechanisms of change involved (emotion and empathy apparently play a major, but underspecified, role). It is also noteworthy that all these theories are theories of guided self-help, with a professional helping the reader to tease out and apply what is valuable from the reading experience, but that the precise relations between the input from the text and from the therapist input remain fairly opaque.
Finally, Detrixhe’s comment also illustrates a general trend in the field to use ‘fiction’ as a synonym for ‘literature’, and thus as a catch-all for the kinds of texts used in creative bibliotherapy – implying that the factuality or otherwise of a text is the key dimension of relevance, and sidelining the potential importance of different dimensions, like narrative–discursive or prose–verse. Doubtless thanks in part to the influence of this tendency, the present study was designed in a way that makes the fiction–nonfiction distinction central, but as will become clear, the results suggest that it may in fact be something of a red herring. There is no perfectly neutral term to encompass all potentially relevant textual forms, but in what follows I will use ‘literary’ to denote all narrative and poetic textual genres (with no value-laden exclusion of contemporary, ‘popular’, or non-canonical, literatures) except where specific findings from the present study require references to ‘fiction’.
In addition to its privileging of fiction over other narrative or poetic forms, the dominant conception of the structure of creative-bibliotherapy-supported change involves many other assumptions about the type of text that should be used, including a range of value judgements about what constitutes suitably high-quality fiction [18], but most importantly the idea that the text should deal with characters and situations (specifically, problem/illness scenarios) as similar as possible to the reader’s own, and should provide detailed and realistic progressions towards a happy ending that resolves the problem [17]. No acknowledgement is made of the fact that reading a work of fiction (or other literature) written by someone else is different from, say, rereading one’s own diary, and that any benefits gleaned from such reading which differ from or exceed those of self-contemplation must therefore be due precisely to the gap between one’s own life and what is evoked in the text. When engagement with literary material is a source of self-directed insight, that insight comes, by definition, via engagement with people and worlds different (whether minimally or radically different) from oneself and what one knows. This also raises another unaddressed question: if we are aiming for as close as possible a ‘match’ between character and reader, which are the crucial dimensions of similarity? If suffering from the same illness as the character matters, does age or sex or sociocultural background or educational level matter too? If not, why not?
The classical model also does not allow for any possible value in a form of textually guided exposure therapy in which difficult experiences without happy endings could prompt a therapeutic confrontation with one’s own entrenched responses, followed by a gradual working-through to less dysfunctional patterns by continued engagement with flawed and complex textual characters. This possibility is raised by the beginnings of a CBT-inspired account which is otherwise broadly compatible with the tripartite structures characteristic of earlier theories [13]. This proposal suggests that the therapeutic reading process may involve recognition, reframing, identification, and emotional memories, but also makes space for the possibility that transportation into a textual world may permit critical engagement with entrenched posttraumatic responses that in the everyday world would elicit avoidance and distress [14]. That is, therapeutic fiction-reading need not exert its effects via neatly linear increases in insight and happiness.
In sum, the identification–insight–problem-solving schema dominates the field, but there are good reasons to question it on both empirical and conceptual grounds. For the eating-disorder context we might add another reason: the fact that in chronic eating disorders, levels of insight are often high but the ability to act on that insight very low. That is, seeking methods for heightening insight into one’s own condition by reading about people maximally similar to oneself may often be less valuable than encountering stimuli which through their very difference from one’s own reality generate a direct capacity for action, or indeed the belief that action could really lead to meaningful change.
We thus have several grounds for systematic research informed by attention to language as an elicitor of psychological change: 1) the first encouraging steps towards an empirical evidence base for therapeutic efficacy; 2) the sheer breadth of possibilities for fiction and other literary forms to expand one’s experiential horizons, from experiences of the fantastical and the sublime to access to the lifeworlds of the nonhuman and the extraterrestrial [22]; and 3) the fact that literature is without doubt already being used as a therapeutic tool, whether formally through institutions or more instinctively by individuals.
Creative bibliotherapy and eating disorders
This paper builds on the theory and evidence presented thus far, taking eating disorders as a test case for the therapeutic relevance of textual genres other than self-help, and presenting the results of an exploratory scoping survey conducted in collaboration with the UK’s leading eating-disorder charity, Beat. But why eating disorders? The choice is not an arbitrary one: eating disorders are a particularly promising context for bibliotherapeutic research and practice for several reasons.
First, eating disorders are culturally inflected in salient ways, not least via the bodily ideals promoted in both image and text by online and offline media. On the anti-therapeutic side, pictorial depictions of the ‘thin ideal’ have been linked to women’s internalisation of this ideal, body dissatisfaction, and eating behaviours and beliefs [23], with conventional and social-media images potentially playing different roles [24]. Meanwhile, pro-anorexia websites exploit in varied ways the capacity of language to express and encourage psychopathology [25, 26], and beyond the realms of the body and illness, relatively homogeneous valuation of qualities such as self-control, self-denial, and restrictive notions of moral acceptability (especially for women) in post-industrial societies may also contribute to the development of value systems that feed disordered eating (whether or not to the point of a clinically diagnosable eating disorder).
Eating disorders have long been theorised in gendered terms as part of feminist discourse [27,28,29], but the development of feminist principles into treatment practices remains relatively rare [30]. That is, despite the general acceptance of a ‘biopsychosocial’ model of eating disorders, all three components are not treated equally [31] – and of course the ‘cultural’ is left only implicit within the ‘social’ category. But findings which suggest that prevalent cultural constructs can have detrimental impacts are a clear invitation to investigate the other side of the coin: whether different cultural inputs could have therapeutic effects. Literary texts may, of course, work hand in hand with other media. Conversely, however, linguistic and literary forms which do not replicate obviously constricting cultural norms have the potential to offer alternatives to inflexibly defined physical ideals and constrictive patterns of thought and behaviour – whether or not these relate directly to patriarchal forms of oppression.
In her book Is Literature Healthy? [32] Josie Billington suggests, for instance, that part of literature’s value is that it is the single area of our culture which seriously explores (and invites exploration) of the ‘inner life’. In The Concept of Literary Application, Anders Pettersson offers a nuanced model of the common readerly tendency to ‘apply’ literature to their own lives: through the qualities of concreteness (vividly evoking specific moments in time and space and experience), intentional design (giving the impression of being endowed with deeper meanings), openness (permitting multiple possible and appropriate interpretations), and a non-pragmatic context (not calling for immediate action), literature is, he suggests, ‘conducive to formation of nuanced perspectives on personally important matters in life’ [33, p.63] in ways that more abstract, shallow, closed, or pragmatic cultural forms are not. This model bears some relation to Russian Formalist (e.g. Shklovsky’s) and Czech Structuralist (e.g. Mukarovsky’s) theories of literariness as the capacity to induce changes in perception through foregrounding: through formal deviations from the norms of everyday language [34, 35]. In this model, without the formal disruptions characteristic of literary language use, cognitive change will not happen; with their help, anyone may potentially benefit from the shifting of habitual forms of thought and perception. Each of these theories has the beginnings of an evidence base, and all offer promising points of departure for investigating literature’s capacity to intervene in the culturally susceptible sphere of the eating disorder.
Secondly, eating disorders involve profound disruptions of embodiment: in particular, an over-emphasis on the numerical, visual, or otherwise externalised aspects of the body (size, weight, shape) at the expense of lived corporeality, often manifesting as a feeling of disconnection or disembodiment [36]. These disruptions always have cognitive components, but they are also always both effects and causes of changes in bodily states: shaped by and further exacerbating semi-starvation in anorexia, for example, or binge-purge/restrict cycles and the resulting bodyweight and endocrine fluctuations in bulimia. This means that simple behaviours which have a direct impact on the bodily state – eating more, exercising less, and so on – can make profound contributions to halting and reversing the progress of the illness. This in turn means that what is needed in the first instance is not the complex psychological work that might be required earlier on to tackle a condition like social anxiety disorder or even depression (though simple behavioural changes can obviously be powerful in those cases too); instead, what one needs is the motivation to change: to act differently; to eat differently. This requires at least some degree of belief that eating differently could make for a different kind of life, or a different way of understanding life – a belief that may be fostered by reading about people far removed from one’s own straitened circumstances. One possible facet of the therapeutic efficacy of reading literature may therefore, as mentioned in the previous section, be its potential to catalyse changes to attitude and thereby behaviour – whether or not through the generation of identification followed by the heightening of insight, as proposed in the well-known existing models.
A fundamental characteristic of the body-mind interactions that constitute eating disorders is the presence of self-perpetuating positive feedback loops which initiate the disorder and sustain it [37], and it is possible that cultural factors, including literary reading, may intervene in these loops for good or for ill: either heightening the instability or mitigating it. This capacity for culturally mediated effects may again be especially pronounced in eating disorders (and disordered eating more generally) because of the directness with which attitude can affect eating and eating then affect the whole mind-body system. This in turn is one of the most important arguments for incorporating any exploration of ‘cognitive’ manifestations of eating disorders (such as ‘body image’) into the broader context of interdisciplinary research on embodied (or ‘4E’: embodied, enactive, extended, and embedded) cognition [38]. The idea of combining both cognitive (e.g. neuroscientific) and embodied approaches with approaches focused on social and cultural factors is gradually gaining traction in eating-disorders research [39], and such rejections of polarised perspectives will be essential to more fully understanding any ‘mental’ illness.
Thirdly, literary texts, perhaps especially those that take narrative (as opposed to poetic or discursive) form, can be thought of as prompts to interpretive processes that have become disordered but are susceptible to therapeutic reconfiguration. Interpretation is a basic function of the human mind, and narratives can be both the vehicles and the products of interpretive activity. For example, the stories we tell ourselves about illness and health may take the form of self-generated, possibly non-verbalised narratives, which shape the experience of a given reality even as they concretise it [40]. Conversely, narrative structures created by others may provide the moulds by which our own interpretations are structured – or against which we rebel. These other-generated narratives may be as directly health-related as the taking of a medical history [41] or as broadly existential as a Modernist novel.
In eating disorders, the functions of interpretation can be seen as distorted at several points on a spectrum of over- to underactive interpretive engagement. At one end, as noted, sufferers may over-attribute significance to specific (often inappropriately externalised or objectified) body- and food-related stimuli [42, 43], and at the other, they may have avoidant attitudes towards the embodied experience of hunger that are predictive of clinical outcomes [44]. In the space in between, multiple and unstable shifts in body image can be elicited by over- or misinterpretations of perceptual, physical, emotional, and social cues [45]. As a complex prompt to interpretive processing at a remove from the raised stakes of immediately self-directed interpretation and from the narrow ideological agenda of much media output, literary texts have clear potential to intervene in the embodied pyschopathology of the eating disorder. The exploratory research presented here begins to establish how that potential may play out in practice, by asking people with and without a personal history of an eating disorder how they see the connections, if any, between their reading habits and their mental health.