Mind the Gap: Do Librarians Understand Service User Perspectives on Bibliotherapy?

Bibliotherapy schemes aim to improve mental health and well-being. Schemes focus on engagement with either imaginative literature or self-help texts and are now commonplace in U.K. public libraries. Impetus for bibliotherapy schemes was influenced by health policy and a drive toward partnership working. There is a recognized need for in-depth evaluation of bibliotherapy services; the lack of evaluation is problematic, as the schemes are designed without reference to service user perspectives. There is a need to identify and analyze usage to assess effectiveness of the schemes. Drawing on data from interviews and focus groups with library and health professionals and service users, this article explores the service provider and service user perspective on bibliotherapy schemes. It concludes that—for service providers—there is a lack of clarity and understanding about how bibliotherapy works, and this impacts on the experience of service users. While service providers and service users share a common goal of improving mental health and well-being, their understandings of bibliotherapy differ, meaning there is a potential gap between service provision and service user needs. The article concludes that in-depth research influenced by user-centered design principles, may help to improve services in practice. Introduction Bibliotherapy is the use of written materials (fiction, nonfiction, or poetry—typically in book form) as psychosocial support or psychoeducational treatment. Since 2001, bibliotherapy schemes have been offered in U.K. public libraries, and surveys reveal that librarians play a significant role in managing these schemes, often in partnership with healthcare providers (Hicks et al., 2010). The aim of the schemes is to provide access LIBRARY TRENDS, Vol. 61, No. 3, 2013 (“Research Into Practice,” edited by Sheila Corrall and Barbara Sen), pp. 569–586. © 2013 The Board of Trustees, University of Illinois 570 library trends/winter 2013 to selected materials, which will have a positive impact on mental health conditions and general well-being. Recent U.K. government initiatives focus on the measurement of wellbeing as an indicator of social conditions, placing improving well-being at the center of government policy (Matheson, 2011). Current government health policy emphasizes the importance of information provision and a life-course approach to tackle mental health problems (Department of Health, 2011). Bibliotherapy is a nonmedical intervention that fulfills these agendas and enables public libraries to contribute to this broad wellbeing agenda. It can contribute to desired outcomes as a cost-effective, nonmedical resource to improve mental health and well-being (Bower, Richards, & Lovell, 2001). Although bibliotherapy as a concept has been in use since 1916, these recent developments have led to a resurgence of the practical application of bibliotherapy in the United Kingdom (Crothers, 1916). Bibliotherapy schemes have achieved widespread popularity in the United Kingdom, with over one hundred local authorities operating a scheme, but there is a lack of up-to-date knowledge about current practice (Frude, 2008; Hicks et al., 2010). The present article makes a timely contribution to updating knowledge of existing schemes, examining their strengths and weaknesses in light of questions of user-centered design (Blomkvist et al., 2003). The article demonstrates the need to comprehensively evaluate the schemes and to translate this evaluative research into practice and policy to improve the accessibility and usefulness of bibliotherapy schemes. The focus here is on the relationship between bibliotherapy schemes and the use of reading as therapy by people with mental health problems. There is currently top-down implementation of service provision, coupled with limited evaluation of bibliotherapy services, with service providers not fully identifying all of the uses and benefits of bibliotherapy, leading to an undervaluing of the services. In the current challenging financial environment, it is important for public libraries that their contribution is recognized. The research identifies new directions for policy and service provision, focused on a user-centered perspective to improve well-being and enable libraries to demonstrate how they are an important source of health and well-being information and support. The data presented here are taken from two exploratory studies of bibliotherapy conducted for masters-level and doctoral research at the Information School, University of Sheffield (Brewster, 2007, 2011). The article is set out as follows. Bibliotherapy is first discussed and defined in relation to the research literature. The article examines the three models dominant in the United Kingdom, then considers the context in which these schemes have emerged, revealing a limited evidence base for the design of the schemes and a top-down approach to implementation. The main data collection methods (interviews and focus groups) and theoretical 571 bibliotherapy/brewster, sen, & cox framework (interpretive interactionism) are outlined. The findings highlight that library and information services staff and their colleagues in the health sector have been unable to evaluate the schemes, driving their direction without user input. The findings then explore interview material gathered from service users to draw a contrasting picture of how readers use books to improve their well-being, identifying a gap in understanding between service providers and service users. Practical examples of usercentered bibliotherapy are presented. Finally, the outcomes of the analysis are discussed, focusing on the value of conducting research that can be taken forward to inform policy and practice, and the article concludes with recommendations for practice. Bibliotherapy in the United Kingdom Bibliotherapy is defined as “a form of supportive psychotherapy in which the patient is given carefully selected material to read” (National Library of Medicine, 2009). This definition is concise yet limited, in that it does not engage with the recent U.K. practices of bibliotherapy. There are currently three main models of bibliotherapy used in the United Kingdom, with some variations. One model, Books on Prescription, provides a list of recommended cognitive-behavioral therapy (CBT)-based self-help books to access and use as psychological treatment (Frude, 2004). The second model, the Reading and You Service (widely known as RAYS), operates groups that read aloud and discuss selected fiction and poetry and also focuses on individual discussions and other therapeutic activities, including creative writing (Duffy, Haslam, Holl, & Walker, 2009). The third, Get into Reading, is similar to RAYS but focuses only on group reading of a smaller canon of texts (Dowrick, Billington, Robinson, Hamer, & Williams, 2012). As more creative models, RAYS and Get into Reading have a social understanding of mental health problems, providing psychosocial support. The aim of Books on Prescription is to provide self-supported psychological treatment. Its emergence as a scheme was motivated by increasing demands on psychological care that could not be met by current resources (Frude, 2004). Patient dissatisfaction caused by increased waiting times for psychotherapy was also a factor considered in the implementation of the scheme, combined with a need for cost-effective, accessible, evidencebased care for mild to moderate mental health conditions (Frude, 2008). Thus, the model was designed using the existing infrastructure of health care in general practice (e.g., physicians’ surgeries) and the public library to widely distribute evidence-based CBT resources using a prescription method (Frude, 2004). The model transferred findings on the effectiveness of self-help bibliotherapy and guidance from the National Institute for Health and Clinical Excellence (NICE) into practice (NICE, 2004; 2011). The focus of the scheme around a specific booklist of mainly CBT-based self-help texts means that it is the least flexible model of bibliotherapy currently operating, and there have been criticisms about its accessibility 572 library trends/winter 2013 for those with lower literacy levels (Richards and Farrand, 2010; Martinez, Whitfield, Dafters, and Williams, 2008). While over 100 Books on Prescription-type schemes operate in the United Kingdom, there are no national standards, and there is some disparity in service provision. A lack of evaluation means that variations in service provision are not always in response to service user feedback but may alter because of other external pressures. For example, some public libraries just hold the collection of titles and do not facilitate access via prescription because the local health service is not in a position to run a partnership scheme. However, differences may also be taken as evidence that some schemes are responsive to service user needs—for example, public libraries in the metropolitan borough of Tameside (2011) now provide shorter titles with lower reading ages; online, DVD, and audio resources; and self-help books in community languages. There is a need for localized understandings and adaptable models responsive to the needs of those who use bibliotherapy schemes. In contrast, RAYS can be regarded as the most flexible model of bibliotherapy currently operating; it uses any imaginative literature, including contemporary and classic novels, short stories, and poetry to achieve its aims of increased public library use, enjoyment of literature, and awareness of the well-being benefits of reading (Duffy et al., 2009). The project developed over time to include work with people with more enduring mental health problems and adapted to meet their needs. Its work also aims to be socially inclusive, engaging with people who may not usually use the library and offering outreach work in a variety of locations as well as working with groups in the public library (Duffy et al., 2009). The final model of creative bibliotherapy currently in operation, Get into Reading, emerged from the School of English at the University of Liverpool. The aims of this project include providing increased access to the literary canon (e.g., Dickens, Tolstoy, or Tennyson) and self-improvement (Davis, 2008). As the project evolved, there was a shift from the recognition of the educational benefits of reading to the health and well-being benefits. Get into Reading is regarded as a social outreach project, aiming to tackle the problem of the low number of people—particularly from deprived backgrounds—reading the literary canon. Its focus on perceptions of high-quality literature makes it less flexible than other models of creative bibliotherapy, although it responds to the needs of those participating in its reading groups by reading aloud and focusing on short stories rather than novels with some groups (Dowrick, Billington, Robinson, Hamer, & Williams, 2012). The design of the Get into Reading scheme also excluded the views of service users within its construction. The formulation of the scheme around the literary canon, reading books that are regarded as “classics,” implies the placing of a value judgment on literature, suggesting that some 573 bibliotherapy/brewster, sen, & cox titles are better for the reader than others. As Gold (1990, p. 24) states, “What is regarded as great literature is what the authorities have decided will last,” critiquing notions of the literary canon in relation to narratives of power. Similar debates abound throughout the academic literature discussing the provision of materials in public libraries, with some authors concluding that the aim of libraries is to provide literature for the betterment of the general populace, with others arguing that libraries should provide the materials that readers want to read rather than those they “should” read (Black, 2006; Stewart, 2006; Usherwood, 2007). The conceptualization of classic literature as the correct literature to read does not allow the reader to place their own value judgment on the texts and does not allow for the possibility that the reader will not enjoy the texts. This contrasts with the other creative bibliotherapy scheme (RAYS) operating in the United Kingdom, which places an emphasis on the idea that “there are no right or wrong books to read” (Duffy et al., 2009). Their statement that “every response to the novel is unique to the individual” suggests a more socially inclusive scheme, focused on the use of a variety of literature (Duffy et al., 2009). As outlined, RAYS can be considered to be the most flexible model of bibliotherapy, using all imaginative literature and poetry as needed. However, in practice, there are still some aspects of bibliotherapy required by participants that are not included, such as accessing practical, symptom-related information. The emergence of these three schemes has been influenced by developments in health and social policy, including an increased focus on social well-being, particularly with regard to Books on Prescription, which meets a distinct policy need. Bibliotherapy schemes emerged to fill a very real need at times of limited funding and increased demand on psychosocial and psychoeducational methods of support. However, they also demonstrate that factors other than service user needs have an impact on the provision of services. Research from other disciplines including assistivetechnology research and information systems design emphasizes that usercentered design perspectives may create services that fulfill service user needs more efficiently, more effectively, and with greater benefit to service users (Blomkvist et al., 2003; Newell, Gregor, Morgan, Pullin, & Macaulay, 2010). The integration of user-centered principles into the provision of library services has also been widely discussed but not consistently applied (Dalrymple, 2001; Zweizig, 1976; Zweizig & Dervin, 1977). The present article therefore aims to answer the research question of whether this model of service delivery has led to gaps between the understandings of service users and service providers regarding bibliotherapy.