November/December 2016 Issue

Bibliotherapy: The Healing Power of Words
By Kate Jackson
Social Work Today
Vol. 16 No. 6 P. 10

Social workers are recommending reading and writing to their clients as adjunct therapies — with positive results.

The benefits of bibliotherapy—the use of the written word for therapeutic purposes—have been known for centuries, even millennia. The ancient Egyptians, for example, acknowledged the power of words to do more than render facts or tell a tale: Inscribed above the portal to the library of Pharaoh Ramses II were the words "the house of healing for the soul." More than 3,000 years later, Abraham Lincoln also pointed to important aspects of bibliotherapy—empathy and shared experience—when he said, "Books serve to show a man that those original thoughts of his aren't very new at all."

"Bibliotherapy uses literature, in any form, that can help us find our way through psychological, emotional, and social problems," says Sandra Marinella, MA, MEd, an author and award-winning educator whose book, The Story You Need to Tell: Writing to Heal from Trauma, Illness or Loss, will be published in Spring 2017. The term bibliotherapy, she says, "can be traced back to the early Greek words for book, 'biblion,' and for healing, 'therapeia.' There can be no doubt that we have always turned to words to help us with the healing process." Bibliotherapy is really an art, Marinella says, "the art of using literature and words to help us find our way in a confusing world."

Long the domain of librarians, particularly those in hospital settings, bibliotherapy was taken up by medical professionals such as Benjamin Rush and Anna and Sigmund Freud in the early 19th century, when the term was coined. Soon training programs arose, bibliotherapy began to be used in hospitals and other health care settings, and it became the subject of studies published in medical journals such as Lancet. Today, it's widely used by social workers and other therapists and increasingly is studied for its ability to relieve distress associated with numerous illnesses and behaviors. Studies have demonstrated its effectiveness, for example, in helping individuals with depression, anxiety, stress, low self-esteem, eating disorders, addiction, sexual dysfunction, somatic symptom disorder, and illness anxiety disorder.

Healing Through Reading and Writing
If it sounds unfamiliar, consider that many of us have engaged in a type of bibliotherapy for most of our lives while reading books, by empathizing or identifying with characters or gaining factual information about our problems, or when we've written to express ourselves, by composing letters, journal entries, or stories. Reading for pleasure, with no motive to heal, can be deeply therapeutic for many. At some level, social workers are employing bibliotherapy any time they simply though strategically recommend a book to a client. Whether they call it bibliotherapy or label it with a number of terms for similar, if not identical, practices such as poetry therapy, journal therapy, or writing therapy—the common denominator of each being the expressive use of words—therapists can also combine this approach with other therapeutic methods such as cognitive behavior therapy to help almost any client.

To define bibliotherapy, Wendi R. Kaplan, LCSW, a certified poetry therapist, points to the tagline of the National Association for Poetry Therapy: "Promoting growth and healing through language, symbol, and story." That, she says, describes it succinctly. In an article called "Poetry Therapy: Through the Lenses of Arleen McCarty Hynes and Mary Hynes-Berry and Peggy Osna Heller," she added, "The elegance of the poetry therapy process is like no other. It is a thoughtful and creative process that allows one to look at oneself, at others and the world through literature in a way that both expands one's perspective of life as well as a way of knowing more deeply and more specifically about oneself. The journey is new and different each time simply because the participants inform it and mold it and the relational dance of poetry therapy blooms as the process unfolds."

While Kaplan says that bibliotherapy evolved from a library science tradition of prescribing books for particular concerns, the process "is now interactive and moves beyond simply reading and into discussion and expression. It includes the use of literature of all kinds, including poetry, book passages, quotations, songs, storytelling, even segments of movies and video to help a person focus on what personal meaning it holds for them, and then to express themselves through journaling, writing, painting, dance, movement, or art in ways that help them bring themselves to deeper understanding and awareness," she explains.

"The work of psychologist Keith Oatley shows us that stories can work as training instruments to help us navigate our problems," Marinella says. "Oatley argues that we use our experience to figure out what others are doing or thinking, and literature works in the same way," she says.

Bibliotherapy has wide application for social workers, health care professionals, and educators. According to Kaplan, it's a "user-friendly" method that can be employed with individuals or groups, couples, and even families. The ability to read or write isn't a prerequisite. Kaplan explains that children and others who can't read or write can listen and have others write for them. "Since reading and storytelling are universal, these activities can be used across the developmental spectrum," says Janet Barlow, LCSW, who has a private practice in Portland, Oregon. "As an expressive therapy that's both flexible and adaptable, it can be incorporated in work with clients of all ages." She's used it with clients ranging in age from 5 to 83 years old.

Kaplan says, "Bibliotherapy really can be used with almost everyone because it's a creative process and it taps into the creativity of both the therapists and the people they work with." She's applied its techniques in her social work practice with teens, cancer patients, substance abusers, survivors of abuse, people with body issues, clients with depression and anxiety, trauma victims, and people coping with loss and other transitions, such as parenthood, moving, or graduating. Often it allows individuals to see how others have faced a particular problem or how their feelings are represented by others. Marinella, for example, recalls a young student who had cancer who had an intense response to I Am Third, the autobiography of football legend Gale Sayers. "As soon as he finished reading it, he wanted to read it again so he could 'learn to have courage' as he faced his own disease."

Barlow finds bibliotherapy especially useful for "anxious clients who have used an intellectual understanding of an issue to help structure and frame their personal experiences. Just as a child may feel more freedom to talk and reveal themselves while they are using a puppet to speak 'for them,' so can adults use their experience reading a book to express themselves in a more indirect, less threatening way," she says. "The self-censorship and protective mechanisms that arise in therapy can become less prominent when someone is describing their reactions to, or opinions about, a character's struggles with similar issues from the more distant third-person perspective," she says. Barlow gathers from that discussion "information about how clients view themselves; how they see themselves in relation to others and the world; how they receive, process, and express emotions and thoughts; how they cope with difficult situations; and whether they have hope or a belief in their ability to change."

Barlow lets the client reveal whether bibliotherapy might be a useful approach. "I typically discover early on in therapy if a client is a 'literary information seeker,' someone who finds solace and support through the written word. If clients mention books or articles they have read, usually about the issues that bring them to therapy, this provides further information about how they wrestle with and make sense of their issues, process information, structure their anxiety, identify with an issue, and judge or accept themselves accordingly," she says. "Their reading often centers on factual information about an issue—self-help books, diagnostic tests, assessments, or an academic exploration of the issue." Barlow typically suggests recent books of literary fiction or memoir that align with the type of reading the clients have done in the past. "This helps to gently open the door to a more personal understanding of their issues."

"Book talks," Barlow says, are helpful at every stage of therapy, "including assessment and ongoing evaluation, deciding on treatment course options, and enhancing and deepening the therapeutic relationship."

One of the main benefits of bibliotherapy, Barlow says, is that it helps individuals see, as Lincoln suggested, that their experiences aren't unique. The practice, she says, gives clients "the chance to experience the universality of human experience and emotion. This 'normalization' process occurs in therapy but can be augmented and expedited with the judicious use of bibliotherapy. This universal understanding can be further enhanced by reading fictional works that apply to the particularity of the individual or the issue." For example, she says, individuals who are chemically dependent may gain insight from reading memoirs by addicts. "A benefit of recommending memoir is embedded in that genre's narrative arc: emergence and progression of the addiction, the attendant consequences and behaviors associated with addiction, a growing awareness and understanding of the need for help, achieving and maintaining sobriety, and the vicarious transmission of hope," she says. "Along with acceptance of their addiction," she adds, "clients often develop more compassion and empathy for themselves and for others through their identification with the narrator's struggles." The same is true of memoirs pertaining to a variety of problems, diseases, or mental health issues.

Bibliotherapy isn't only useful for patients with diagnosable illnesses or distressing behaviors. It can be helpful at a simpler level as well, improving clients' ability to cope with daily experiences or understand larger social issues. As a teacher after 9/11, Marinella recalls that her students "wanted to be able to understand war and be able to talk about it before they had to go fight in it. They wanted to dig deep and make sense of what their country was facing." They were passionately drawn, she says, to books such as Erich Remarque's classic All Quiet on the Western Front, Elie Wiesel's Night, and Tim O'Brien's The Things They Carried. "I believe our discussions of these books helped them find their voices and establish their own thoughts." Similarly, she observed that reading helped students cope with issues such as student rivalry. "A book I found especially helpful for teenagers is A Separate Peace by John Knowles. "It has a charming, daredevil main character named Phineas and his introverted roommate Gene. While Gene loves his best friend, he also deeply resents him, and this leads to a tragic event." Marinella found the book to be cathartic for young people, helping them "grapple with and face petty jealousy, resentments, and competitive rivalry."

Writing to Heal
While reading is therapeutic, it's not the only practice embraced by bibliotherapy. Writing is equally beneficial. Kaplan points to the work of James Pennebaker, PhD, on the healing effects of writing, which she says has been most widely duplicated and expanded upon. "We look at brain research, as it shows neurons that fire together wire together," she says, adding that Deborah Ross. LPC, and Kathleen Adams, LPC, "have expounded on this in their wonderful book, Your Brain on Ink, which addresses the benefits of writing and neuroplasticity."

"I use the term creative 'righting,'" says creative arts therapist Sherry Reiter, PhD, a clinical social worker and registered poetry therapist, "to connote achieving emotional balance. Writing, she explains, accomplishes several things: "identification and clarity of emotion, emotional regulation and catharsis, and reflection and insight."

Marinella has worked with veterans and cancer patients using writing to work through difficult periods in their lives. "James Pennebaker's research in the last three decades has established that writing is a powerful healing tool as well."

Recently, for example, she worked with a veteran who had been raped more than 20 years ago. "In our writing group, week by week, she slowly began to create poems revealing 'her secret,'" Marinella says. "She had found her voice, and in doing so she was able to move past the anger she had carried inside her for many years."

"Sometimes the truths we learn are the starting points for healing," says Reiter, author of Writing Away the Demons: Stories of Creative Coping Through Transformative Writing. "Sometimes the words emerge unexpectedly." She recalls a poetry therapist working in a day treatment center who read the Charles Simic poem "Stone." She gave each person a stone and asked, "If your stone could speak, what would it say?"

"A woman who had been selectively mute spoke for the first time in several weeks," Reiter says. "Her words stunned all in attendance: 'I am the stone. I am broken. I came from something so much larger. But now I am small. Now I am nothing.' This was the starting place for healing." Through this expression, she let the group know about her need and they responded in nurturing way.

When Words May Not Heal
Although bibliotherapy can be highly effective, it may not be for everyone. When considering the use of the practice, Kaplan says, it's necessary "as with any other client, to assess individuals for their abilities to comprehend, respond, and interact. We would also assess their general mental health and abilities." It's not recommended, Reiter says, for persons who are psychotic and unable to tell the difference between reality and fantasy.

Barlow doesn't recommend the use of bibliotherapy with certain clients—for example, those who don't reveal reading as a means of gathering information or gaining understanding, who have a limited attention span or lack the ability to sit and read, or who have low self-esteem about academic or reading abilities. In addition, she avoids the use of this technique in clients "who demonstrate a significant amount of transference toward the therapist and who may take any book suggestions as a veiled diagnosis or criticism or imbue the suggestion with additional meaning."

And for some clients, a little time may be needed before introducing bibliotherapy. "When clients are in the throes of a new trauma, you don't want to rush them into reading or writing about a difficult experience, Marinella says. "Some recent research points out that the power of silence helps our brains regenerate. Whenever a personal story has been shattered, it takes a while to adjust to the change. We have to allow for that."

Learning More
Marinella recommends that social workers interested in learning more about bibliotherapy or pursuing training explore online classes and certification programs offered by organizations such as the International Federation for Biblio/Poetry Therapy (ifbpt.org), the National Association for Poetry Therapy (poetrytherapy.org), and the Therapeutic Writing Institute from the Center for Journal Therapy (journaltherapy.com). In addition, Reiter says the Creative Righting Center (http://sherryreiter.blogspot.com), of which she is the director, has ongoing intensive training sessions for helping professionals.

Kaplan enthusiastically advises social workers to discover and study bibliotherapy. "It's fun, thought-provoking, inspiring, elegant, creative, evocative, and interesting," she says. "It expands you as a social worker, enlivens your work, and has endless applications."

— Kate Jackson is an editor and freelance writer based in Milford, PA, and a frequent contributor to Social Work Today.