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Abstract
Public health strategies have placed increasing emphasis on psychosocial and arts-based strategies for promoting well-being. This study presents preliminary findings for a specific literary-based intervention, Shared Reading, which provides community-based spaces in which individuals can relate with both literature and one another. A 12-week crossover design was conducted with 16 participants to compare benefits associated with six sessions of Shared Reading versus a comparison social activity, Built Environment workshops. Data collected included quantitative self-report measures of psychological well-being, as well as transcript analysis of session recordings and individual video-assisted interviews. Qualitative findings indicated five intrinsic benefits associated with Shared Reading: liveness, creative inarticulacy, the emotional, the personal and the group (or collective identity construction). Quantitative data additionally showed that the intervention is associated with enhancement of a sense of ‘Purpose in Life’. Limitations of the study included the small sample size and ceiling effects created by generally high levels of psychological well-being at baseline. The therapeutic potential of reading groups is discussed, including the distinction between instrumental and intrinsic value within arts-and-health interventions.
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Introduction
The surging popularity of reading groups has been deemed ‘the success story of literary culture’ (p.2),1 and literature's capacity to promote well-being has a long, distinguished provenance. While ‘bibliotherapy’2 (which generally involves self-help material) has demonstrable benefits for adults experiencing mild to moderate psychiatric difficulties,3–8 increased attention is also being paid to the therapeutic potential of fictional prose and poetry.9–11 This is a tradition that emphasises literature's power to offer emotional recognition and relief, a language to ‘express complex experience as a means of tolerating and surviving it’ (p.16)12 and the ability to convey embedded, tentative elements of human experience, wherein readers can identify and symbolically explore issues raised within a text.13 Aligned theorising around reading and health similarly posits that communal reading can augment interpersonality, both between text and reader, and between one reader and another.14 In turn, neuroscientific research shows that complex poetry has the capacity to stimulate neural pathways in ways that influence autobiographical memory function and emotional processing.15–17 Consistent with recommendations by The Reading Agency for Arts Council England18 which emphasise devoting greater precedence to reading projects within the arts-in-health movement, this study develops an existing evidence-base in relation to the therapeutic use of the literature by reporting preliminary findings from a community-based scheme, Shared Reading (SR).
The intervention
SR is designed and implemented by The Reader Organisation (TRO), an award-winning social enterprise that develops spaces in which people can relate with serious literature and with one another, and where personal responses to texts can be freely shared.19 TRO currently hosts over 360 weekly groups in a diverse range of UK community settings. In order to situate texts as a live presence and emotional centre (as opposed to merely objects of analysis), material is unseen beforehand and read aloud during the session. The intervention is facilitated by TRO-trained project workers, who support fluid, spontaneous discussion of both the text (eg, characters, narrative, language, themes) and subjective responses to it (eg, thoughts, emotions, personal reflection).
SR is premised on the notion that the literature ‘offers a model of, and language for, human thinking and feeling with the potential to ‘find’ and alleviate personal trouble and thus to produce therapeutic benefits’ (p.16).12 It is a practical intervention that offers utility in diverse settings, including prisons,20 adults experiencing social disadvantage (eg, vulnerably housed, recovering from substance dependence)13 and patients living with depression,12 dementia,21 chronic pain22 and neurological conditions.23 In reviewing this research, Dowrick et al (p.16)12 conclude that SR ‘not only harnesses the power of reading as a cognitive process, but also acts as a…socially coalescing presence, allowing readers a sense of subjective and shared experience.’ Cited benefits are broad, with outcomes covering the emotional, cognitive and interpersonal, for example, enhanced relaxation, calmness, concentration12 ,24 and quality of life;22 increased confidence, self-esteem and mastery;24 feelings of mutuality, shared community, common purpose;12 ,22 ,24 the opportunity for structure and continuity among those whose lives may otherwise be chaotic or unfulfilled;12 ,25 and a safe, social space in which to reflect on personal experience evoked by the text.24
Taken together, SR is congruent with public health strategies26–28 that aim to enhance and sustain well-being by preventative intervention against factors like inactivity and isolation. Indeed, SR has been commended by the Department of Health, and endorsed by General Practitioners (particularly for patients whose mental health is affected by social isolation and for whom standard medical treatments feel unsuitable13). In this respect, there is a strong rationale for delineating the intrinsic value of SR more fully.
Aims
The study aimed (1) to identify intrinsic value components of SR, (2) to examine relationships between this intrinsic value and any collateral and secondary instrumental benefits and (3) to extend the application, and further test the value, of processes for investigating the phenomenology of SR using interdisciplinary (literary, social scientific) methodologies.
Method
Design
A 12-week crossover design compared benefits associated with SR with a contrasting social activity focusing on the Built Environment (BE), which involved touring and exploring the park area surrounding the International Centre for Reading and Wellbeing (Calderstones Mansion, Merseyside), followed by group discussions of design ideas for the Mansion House grounds. While BE provided a clear contrast to SR, it was also selected for offering intrinsic value of its own within the same locale.
Participants
Participants comprised a convenience sample of 6 individuals from TRO's Volunteer Reader Scheme and 10 volunteers from the local community. The former were individuals at risk of, or suffering from, mental health difficulties, isolation or unemployment, and are engaged in a range of volunteering opportunities for TRO (eg, running reading groups in Residential Care Homes). These participants’ vulnerable backgrounds make them representative of some of the communities that SR is targeted to reach. The mean age was 37.8 years (range 21–70) and 11 participants were women. To avoid bias from preconceptions about SR, volunteers were only recruited if they had no previous experience of the intervention.
Procedure
The research was advertised via TRO and at a Calderstones Mansion open day. Those interested in taking part were invited to a follow-up session to receive information sheets and consent forms. Before study commencement, an introductory session with the research team was held at Calderstones Mansion where the project was fully described both verbally and in writing.
Participants were divided into two groups comprising three TRO volunteers and five local volunteers, and undertook 6 weeks of SR and 6 weeks of BE. Group A commenced with SR, which was counterbalanced in Group B who experienced BE first. All sessions lasted 1.5 h and occurred on consecutive Friday mornings from September to November 2013. SR was led by the founder of TRO, and BE was facilitated by the director of Prosocial Place, a social enterprise aligned to a research programme directed from the University of Liverpool exploring the relationships between mental health and well-being, physical, and social places. All data were collected at Calderstones Mansion.
Reading material was taken from TRO's resource bank.29 Sample texts included short stories Faith and Hope go Shopping by Joanne Harris and self-contained excerpts from the novels Great Expectations by Charles Dickens and Silas Marner by George Eliot, and poems such as I Am by John Clare and To Anthea by Robert Herrick. Although SR involves reading aloud, printed copies of each text are also provided for each participant.
Analysis
Audio and video session recordings were made by female postgraduate research assistants, transcribed verbatim and analysed by a multidisciplinary team comprising the Centre for Research into Reading Literature and Society at the University of Liverpool: PD and JB (literature specialists), RC and EL (psychologists) and SL (linguist). Methodological orientation included discourse analysis and ‘realistic evaluation,’30 which investigates complex open human systems and captures a rich picture of action and experience in its full social context.
Transcript extracts were selected on the basis of (1) marking individual breakthroughs/difficulties in relation to both text and group dynamics or (2) representing apparently meaningful moments. These were shown to participants who were interviewed individually, for an hour on average, in order to elicit responses and test some of the study hypotheses (although the questioning, conducted by PD, JB and GF, was designed to be open-ended). In order to build a saturated real-time picture of the reading experience, TRO mentors were also interviewed. Joanne Harris, an author of a text used in the study, was additionally interviewed after watching video excerpts of the group discussing her work.
Quantitative data were derived from a battery of self-report instruments administered at baseline and after each 6-week period: the Positive and Negative Affect Scale31 (PANAS), the short-form Depression, Anxiety and Stress Scale32 (DASS-21), the Dalgard Mastery Scale33 (DMS), the Warwick-Edinburgh Mental Well-Being Scale34 (WEMWBS) and the ‘purpose in life’ (PL) and ‘personal growth’ (PG) subscales of the Ryff Scale of Psychological Well-being35 (SPWB). Participants were additionally requested to generate two words or phrases that best described their experience of each session.
Between-group comparisons were conducted using independent t tests. In order to compare changes within the groups in relation to the two activities, scores were calculated for each measure as follows: mean differences between each outcome measure from baseline to week 6 crossover, and mean differences from week 6 to week 12 following the final session.
Results
Mean session attendance was 8.25 (range: 1–12). Analysis was undertaken with 14 participants who attended three or more sessions. One TRO volunteer attended only the initial BE session, and another attended only three SR sessions. One local volunteer attended a single SR group and did not return, explaining that she did not feel it was for her.
Quantitative analysis
Table 1 displays self-report data following 6 weeks of both activities. Comparisons of SR and BE using mean differences from baseline to 6-week crossover, and week 6 to week 12, are presented in table 2.
Results of self-report measures in response to Shared Reading sessions (SR) and Built Environment (BE) workshops
Mean differences and associated effect sizes in outcome when comparing Shared Reading sessions (SR) and Built Environment (BE) workshops in a crossover design
PANAS data indicated that both activities were associated with substantially higher levels of positive affect compared with negative affect. Although there were no differences between the two, there was a non-significant trend for more negative affect to be endorsed by the group experiencing SR during the first 6 weeks compared with the group experiencing BE first. The associated effect size of this difference was large (Cohen's d=0.93), indicating that a significant finding may have been returned with a larger sample.
There was also evidence that the activities promoted different aspects of well-being. Specifically, the PL subscale of the SPWB improved for both groups after 6 weeks of SR, an effect not replicated with BE. While Group A's PL scores increased from week 1 to 6 with SR, Group B's mean score decreased in the same period following BE. Although this contrast was not statistically significant, the difference was associated with a large effect size. In turn, Group A's mean PL scores decreased in weeks 6–12 following BE, whereas Group B's increased following SR. This difference in PL change was statistically significant (t=−3.09(11); p=0.01) with a substantial corresponding effect size. In contrast, BE was associated with modest, non-significant increases in PG in both groups, whereas SR was associated with small non-significant decreases in PG scores. Compared with SR, feelings of mastery also showed a larger decline when BE was experienced as the initial activity over 6 weeks, which was also associated with a large effect size.
DASS-21 scores showed a small increase from baseline for both groups. However, while these further increased in weeks 6–12 for Group A following BE, they decreased for Group B (SR) in the same period. There was no significant difference between the two activities, although the large effect size suggests that the difference between the groups in terms of DASS-21 change would become significant with larger sample sizes. Finally, WEMWBS scores increased from baseline in both groups, as well as after the crossover. There were no significant differences between the two activities, and there was no indication that WEMWBS scores were affected by the order of intervention delivery.
Qualitative analysis
Qualitative analysis indicated five intrinsic value elements of the SR experience: liveness, creative inarticulacy, the emotional, the personal and the group.
Liveness
While traditional reading groups rely on reading texts in advance, SR emphasises vitality and currency through presenting material for the first time within the session and reading it aloud several times. In this way, the text becomes a vocal, embodied presence that offers a centre towards which participants can gravitate, a dynamic described as follows: ‘It was as though there was a power in the middle of the table…and it was pulling us in’ (S).
In addition to providing a grounding centre for the group, this element of liveness was characterised by a sense of absorption and immersive involvement, wherein ‘each moment became…a world in itself for appreciation’ (An). In turn, the performative model of delivery engendered a sense of novelty and anticipation—of ‘not knowing in advance’—that could transform the reading experience from private interpretation into an immediate and active form of doing. As described by An:I went in…not knowing…When you read…your own experiences comes [into it]…and you identify different parts…I was totally taken aback and it felt so important both on an emotional…and…intellectual level… I felt it mattered and should be pursued, by myself because my own response was so great.
This element of unpredictability can be seen as a substitute for undemanding, convenient defaults. Unpredictability means that routine must be deviated from and uncertainty must be tolerated. Thus, ‘[t]he live reading of unknown texts with (unknown) others removes the facility to rely on …‘safe system[s]’…we cannot predict and so cannot control our responses—instead we react in emotional ways where the function of emotions is to prepare an organism to act in response to environmental challenges…or novel situations’(p.10).36
Creative inarticulacy
The groups demonstrated powerful creative endeavour in terms of transforming and translating inner experience into emergent thinking. In contrast to literal information and opinion (eg, the type of explicit, top-down processing associated with self-help procedures where subject-matter is named and defined), this tended to be implicit and bottom-up, in that it began with the resonance generated by the text.
Explorations of literary experience, content and meaning were thus internally generated by the group, rather than specified in a dogmatic or formulaic way. As such, emotions embodied within the work remained dynamic and live. The author Joanne Harris, viewing a video recording of the groups reading her own work, described this as an increase in ‘emotional articulacy’. In turn, creative inarticulacy rendered the utterance of a thought as a genuine accomplishment (as it is in the act of writing itself). E, who suffers from a neurological disability, described the following process associated with articulating private experience:[O]ne of the things that I find that when I'm trying to put thoughts into words to explain to doctors, it's an impossible, unless I've…sometimes I find something written down and think, that's what I'm trying to explain!…Because unless you find the right words, they don't understand what you're talking about. And sometimes when you read a poem or a story…you're thinking that [the] writer has just hit the nail on the head, and you know, I know exactly what he's talking about.
A sense of uncertainty/tentativeness in discussing texts was generally not a hindrance, more often a channel or prelude to enterprising and stimulating breakthroughs in ideas. Vacillation appeared to permit space, time and consent for imaginative and emergent thought, which mirrored the intrinsic spirit of literary thinking itself. In turn, some moments of the most profound achievement appeared as a ‘relay of thinking’, wherein members collaborated round the text to share, complete and develop diverse thoughts and perspectives in the manner of passing a baton. In this regard, the groups demonstrated a strong sense of creative effort and also of communication and cooperativeness.
The emotional
A starting point for ‘‘doing reading’ actively and dynamically’ (p.16)36 was implicit emotional resonance with the text—‘a felt sense’—in which articulate, ‘educated’ knowledge was often viewed as secondary. For example, M described how learning, in an SR context, was ‘sharing things about life…not a theoretical discussion,’ whereas A identified how ‘[P]oetry can get to feelings very quickly –it's almost condensed […] it just happened quite—suddenly.’ Following preliminary affective responses (eg, ‘sad’, ‘tender’), more explicit, composite analyses would often emerge.
Although SR does not serve as an explicit space to discuss one's difficulties, the sense of human suffering/striving embodied in the texts often provided triggers through which participants could spontaneously engage with painful feelings from differing perspectives. In this respect, treating reflexive, distressing or shameful material as a subject-matter offered a transfigured and more active position, a change of assessment point in which emotions could be accessed and examined in alternative ways, as well as a shift from the passivity of depression or felt anonymity. As H described, when comparing SR with conventional peer-support settings:[I]t's less…miserable…[Y]ou're not sitting around talking about how you feel terrible, everything's going wrong…you're sitting around talking about […] not always good things but things…in a better context…You're kind of looking at them, you're not feeling them yourself necessarily, or not on the same level as I would have been in hospital…I can look at the poem and think about what it means to feel that.
Although emotional primacy did not preclude detailed, inventive attention to a text's composition, this tended to manifest in a dynamic way that exceeded the typical constraints of academic purism. Indeed, a willingness to devote attention to the ‘little things’—small words and phrases, or minor details of a text—that others might not have time for was important to participants. In turn, this use of the small (which can actually contain the ‘large’ at the level of emotional meaning) is crucial to ‘real’ reading at the level of immersed attention, as it means that reading is not passive but takes the given and actively recognises its language and translates it. Joanne Harris also commented thus: ‘[I]t shows a level of engagement which I find creative writing students don't have because they have learnt to disassociate themselves from the piece of writing…they are looking at the artifice and not the heart of it.’
The personal
There were numerous instances of story-telling within the group, as members used the raw materials of the text to facilitate autobiographical recollection (eg, narratives about family members (Silas Marner), memories of cruelty and humiliation (Great Expectations), ruminations on mortality (Rich)). In subsequent interviews, participants observed that (1) relevant memories were ‘triggered’ or ‘tripped off’ by the text and (2) they had not previously disclosed these stories beyond trusted circles and would not normally discuss such issues with comparative strangers. In this respect, the group was felt to provide a ‘safe’, ‘intimate’ and ‘respectful’ space. Specifically, H articulated the concept of a discretionary place within the group, where readers could work and interact between themselves and the text: ‘It was kind of halfway between…telling them everything and telling them nothing. It allowed me to say something, but I didn't feel awkward about it.’
Although fictional works, participants additionally commented on how ‘real’ the texts felt for being read aloud. L observed how the emotional salience of Silas Marner aroused a powerful contemplation of the personal:[I]t's…like a portal…into another person's consciousness…it…evokes a kind of wordless knowledge inside your mind…Yes, it is so real…it's that portal into the accumulated experience of an individual–every single human has that accumulated…store of experiences and memories and I suppose some people are a bit more…aware of it than others–but everybody has the capacity to have that brought back to them…I think you need really, really good writing to do that.
The external stimulus of the text seems to initiate a flow of information processing across and between externally-focussed and internally-focussed attention, wherein external contemplation of the text prompts the temporary switch to the internal recollection and reconsideration of one's own experience in line with on-going textual context. In terms of neuroscience, this represents the switch from the executive network mode of processing to the default mode processing network via the triggering of the salience network. Thus, the text acts as the salient stimuli that triggers the inwards shift in the reader. In terms of everyday conscious experience, this is distinct because we are more often explicitly aware of the shift from the internal mode to a triggered external mode of processing. In SR, the internal focus is unlike the common, recognisable (but nevertheless difficult to report) experience of spontaneous mind-wandering. Rather, it is an explicit, managed engagement with our capacities to recollect, reimagine and simulate that is altogether different. Some of SR's value may lie in this less common consciously triggered and managed reverse-switching of awareness: that participants become involved in a comparative private world while reading and where the significance of that world is determined by engagement with the text. Furthermore, through ‘sharing’, the inner world becomes a shared world, with external relevance and resonance within the group.
The group
Through the influence of the text and facilitation of the Group Leader, SR transformed from a static gathering into a communion of connection, communication and exchange. This was a dynamic process, and the video footage permits a powerful visual impression of emergence and interaction, in which participants repeatedly grouped and re-grouped (respectfully, democratically and independent of age and social class). In this regard, group roles and allegiances were fluid, vibrant and adaptive but unpredictable, hinging almost entirely on given realisations and identifications emerging from the text.
Interactions also reflected an interweaving of both sameness and difference. For example, when asked about group responses to the reading of I Am, H gave the following account of collective refinement and refutation:I think sometimes when you hear what someone else says, you either think, yes, that's what I mean or you think that's kind of what I mean, but you see what the difference is between what they're saying and what you mean. So then you can put that into words easier than you can put your own big idea into words.
In turn, S described how she and two other participants united in their consideration of maternal relationships in response to Great Expectations:At first I think my attitude was oh but you didn't know my mother, thinking that nobody could have been like my mother. And then it gradually dawns on you that there are others the same, so it's a shared experience then isn't it.
Although mandate traditionally implies that diversity and multiplicity ought to be esteemed within a group, at times it was the surprising sameness (across apparent differences) that was more valued. Joanne Harris articulated the richness of group dimensions in the following way:It is happening at various levels. You have people communicating within a group. And people accessing memories and aspects of themselves they may not always be conscious of. And also you've got a level of communication with the writer of the story and what they're expressing. And all this is happening at once. This is why reading groups have become popular: because they are not just about reading, but about what you bring to the table.
Comparison with other group experiences
Six participants disclosed currently or historically receiving psychotherapy. All expressed a preference for SR in comparison, with formal therapy identified as ‘policing, even self-policing’ (M), having an emphasis on negative themes and ‘all sitting here because we were ill’ (H) and that SR did not demand the discussion of ‘issues’ in fixed terms (An).
SR was also considered to offer richer emotional content compared with BE. For example, while personal stories and expressions of vulnerability were felt to be instructive and enriching in an SR context, similar deep emotional disclosures felt prohibited in BE on the grounds of being ‘self-indulgent’ or ‘inappropriate’. When examining session transcripts, it was observed that there was involvement with the text, and this results in self-disclosing talk. In the BE transcripts there was conversational involvement between the coparticipants, in the sense that they were sharing and exchanging opinions with regards to terminological issues, but the talk seemed less interpersonal and more detached. This could be evidenced by comparing the use of conversational features, such as speech representation and story-telling practices that contribute to dramatisation and vividness of the reported text.
When asked to generate words summarising each activity, participants elicited more emotional terms for SR (53.5%) than BE (21%), with a greater distribution of cognitive words for BE (79%) than SR (46.5%). Subjective responses indicated that while BE provided opportunities to look forwards in a positive manner beyond ‘the self’ and into the community (extrospective and future-focussed) SR was more engaged with the introspective and the past (although triggered in the present and felt within both text and group).
Polar themes were also apparent when analysing activity-specific words. For example, SR was characterised by factors like imaginative, nostalgic, simulated, resolution and open as opposed to BE being creative, optimistic, applied, evolving and contained. In this respect, it was observed that despite BE's guiding structure, Group A approached it in a more analytical fashion than the intuitive discussions of Group B—a difference possibly attributable to prior exposure to SR.
Discussion
Conclusions about the interventions, particularly in relation to the crossover design, can only be provisional given the small sample. Nevertheless, the data indicate that SR groups can have beneficial outcomes, even when groups are of short duration, in terms of improving PL. The activity seems to increase the belief that participants have significant goals and that both their past and present life have heightened meaning. Given that even brief SR participation may improve PL (and that this specific change in well-being is a central feature of its intrinsic value), we can draw a specific methodological conclusion about measuring well-being in relation to SR. Specifically, the PL construct does not transmute into improved general well-being as assessed by the popular but over-simplified WEMWBS and DASS-21. As such, it is important that future evaluations of SR measure specific features of psychological well-being using sensitive and applicable instruments like the SPWB.
The association between the two activities and different facets of psychological well-being also exists in the data, since BE involvement appeared to impact upon well-being by improving PG through an increased sense of self-development resulting from knowledge acquisition. This interpretation likewise maps onto the distinction between emotional (resonance) and cognitive (relevance) emphases in the two-word analysis. However, it would be erroneous to exemplify BE as solely practical, given that for most participants it involved imagination and intuition, just as it would be inaccurate to characterise SR as non-practical when it was clearly a dynamic, cooperative process with real-world psychological significance.
Equivalencies in positive affect between SR and BE, as assessed by PANAS scores, likewise indicate that both were enjoyed to an equal extent. Alternatively, it may be a result of the organised social engagement shared between the two, or partially reflect the dispositional nature of the participants. However, it is important to emphasise that BE was not merely a foil for SR: both activities mutually highlighted one another's intrinsic benefits, while sharing the advantages of a group mind-set. However, while in BE the emotional and personal are channelled into the (imagined) creation of an environment through applied external focus, in SR the resonant place already exists in the text and is emotionally activated by the group in ways that are more internally personal.
The indication that SR provokes greater negative affect than BE is instructive and consistent with some of its intrinsic value (ie, literature's power to open individuals up to a range of emotional states). These may be experienced vicariously in sympathy with characters, or be associated with personal episodes/reappraised situations evoked in response to the text. It is also consistent with the idea that describing emotions in binary, polarised terms (negative/positive) is problematic or unhelpful in general, and specifically in relation to SR's value. However, because of the requirement that interventions are not harmful, it is important to note that no evidence points to SR having deleterious effects, even in expanding the experience of ‘negative’ emotions.
The rich qualitative data additionally revealed intrinsic elements of SR that appear strongly conducive to well-being. That the group, and the literature within it, offers a compassionate alternative (and partial antidote) to the experience of being judged, exposed or disregarded within the world, was apparent within the five intrinsic elements arising from our analysis. In this respect, we suggest that there is a need for literary language, or language arising out of deep human engagement, to inform, deepen or modify narrow and over-literal terms within public health agendas: for example, negative versus positive experience; problems, cures, answers, solutions; and therapy itself.
Is SR ‘therapeutic’?
The current project aimed to extend the evidence-base for literary arts-in-health interventions by exploring SR's intrinsic value. Nevertheless, queries regarding therapeutic usefulness are problematic in that they embody the complexities of instrumentalism: is the effect at the expense of the literature which prompts it? Also, is therapeutic too ‘medicalised’ a term for reading's intrinsic value? We suggest that more subtle analyses than the intrinsic/instrumental division may be required—that of ‘implicit’ relative to ‘explicit’. That is, SR's explicit usefulness may be implicit within the experience, in that it places participants in a position from which they can draw out further developmental potential. Indeed, expert facilitation, in the sense of ‘bringing out what is within,’ as well as an exchange of thoughts and beliefs, are strategies with recognised therapeutic value (p.16).12 In this sense, SR might be viewed as ‘implicit psychotherapy’ (Bentall, personal communication) precisely by remaining literary.
In this respect, a relevant factor emerging from our analysis was the experience of changed mental processes. This includes a sense of personal reflection during SR evoking a degree of meta-cognition. As stated by H:It just makes you think about things…on a level that you can actually see, you know in your head you can see what you're thinking rather than it just being part of your general feeling on life…you kind of pinpoint things more.
During such shifts, participants’ experience became compressed in moments of reflection and realisation, rather than being registered lineally. This is illustrative of how live reading reflects tensions between ‘the overall drive towards cognitive efficiency…and the need really to get to the heart of things where deep appreciation/realisation lies’ (p.33).36 Similarly, dualistic discrepancies between ‘negative’ and ‘positive’ become altered at this meta-level. When evoked in relation to the text, incidents of distress, shame or regret could be profitably examined in the same manner that an author might use previous experience to craft her writing. The power of this process was very apparent in the video footage, wherein participants discussed past pain in relation to the text (eg, childhood cruelty: Dickens; disability: Harris; life journeys and unwitting choices: Frost) with a cathartic sense of freedom and energy. Elevating painful material in this way elegantly reflects the creative and transformative fusion of negative and positive in a literary setting. As commented by a TRO project worker, ‘You don't necessarily hear it from…group members but you hear it from the family…that this is the most important thing in the person's week…That things are transforming for them and for the people they are in relationship to.’ In turn, A offered the following reflection on the interconnection of private experience and group involvement:For me in that situation it was more helpful than one-to-one. We spoke in the group today…about how the group's become therapeutic although it's not—therapy. I didn't want the attention to be on me. I didn't want anybody to see that, so the group continued. And you know it was a safe place to feel like that…
As stated by Davis et al, we would propose that ‘[L]iterature widens and enriches the human norm, accepting and allowing for traumas, troubles, inadequacies, and other experiences usually classed as negative or even pathological. It is a process of recovery—in the deeper sense of spontaneously retrieving…experiences and qualities that were lost, regretted, or made redundant’ (p.33).36 In addition to transmuting negativity, this process of recovery also included using the small, in that something seemingly minor and dispensable could contain something larger concealed within. Such surges of realisation were a major aspect of this study, characterised by emergently decisive breakthrough moments wherein participants discovered meaning; transcended norms or habits; attained higher meta-levels of awareness; employed enhanced processes of identification, imagination, and reappraisal; or were roused into the recovery/discovery of previous experience in fresh forms.
Therapeutic for not being therapy? Useful by not being instrumental?
We believe that recovery, restoration or realisation may be more appropriate terms than therapy. Despite stated preferences for SR over formal group psychotherapy, participants did not believe that the literature can solve problems, or indeed that it exists solely for that (instrumental) function. Nevertheless, a sense of personal purpose in the act of reading may be what is reflected in the quantitative findings of the SPWB scale. In psychological terms, this reflects the concept of a ‘salience-uplifter’ (as opposed to psychological depression or epistemological neglect), itself instantiated within the ‘big-in-small’ examples given above. The stimulation of metacognition and high-level mentalisation in relation to deepened and expanded emotional investment in human pursuits (created by the text) indicates such purposiveness in seeking meaning. This is not the same as achieving concrete answers or secure solutions. Rather the activation, in and of itself, has intrinsic value in terms of heightened mental energy and involvement in areas of human concern.
SR requires active rather than passive responses: it necessitates engagement, exchange and liveness; articulate emotional expression from a real (rather than theoretical) reader-response; the cathartic use of painful material; and the humanising presence of the literature in relation to personal contemplation, triggered in areas of experience and meaning otherwise difficult to locate, recover or discuss. In turn, this is a tentative and unpredictable process—a voyage of discovery rather than a distinct endpoint—that occurs in a community setting wherein inner lives come out, and come out together. Taken together, there is a potentially healing effect of a small-group community fashioned from a blending of personal thoughts and feelings, and the intricate and dynamic interaction of individual, group, Group Leader and text.
Limitations
The small sample inevitably meant that the quantitative analyses were underpowered. The findings are thus presented tentatively and should be considered alongside the qualitative analysis, as well as associated effect sizes for group comparisons. Homogeneity within the groups additionally meant there were generally high levels of well-being and mastery, and low levels of affective symptoms, reported at baseline. These relative ceiling effects limit the opportunity for positive change as a result of study involvement. Due to resource constraints, the delivery model was also only 6 weeks, far short of the 24 weeks cited by TRO for improving well-being. However, this, along with consideration of the other limiting factors, adds to the credibility of our main finding of increased self-reported ‘PL’ resulting from SR.
Future research
Investigations with larger samples could yield rich data into the overlap between literary, linguistic and psychological processes occurring at both the individual and group level of SR. This includes comparisons with other SR initiatives, such as those employing non-literary content.
The finding that phenomena inherent within SR may offer implicit value is also a source for further development. For example, future comparative study could examine how SR could be used as an augmentation, or alternative, to Cognitive Behavioural Therapy (CBT). Certain dynamics evidenced in this study offer procedural distinctions that could be usefully explored. In particular, this includes a contrast between spontaneous, evolving processes and imposed, instrumental programmes. SR works from the bottom-up using an unseen text and achieves its effects through breakthroughs in meaning from within an experience. It either implicitly challenges habitual emotions or recovers and transmutes them into new forms. In contrast, CBT operates top-down through executive instruction and disciplined planned stages, designed to function outside the experience and separate from the person. It is important to understand whether the benefits of bottom-up ‘therapies’ may be more sustainable because they are self-driven and integrated, rather than imposed by another and then attempted to be taken on by the self.
Acknowledgments
The authors thank Dr Victorina Gonazalez-Diaz for her valuable comments on an earlier draft of the manuscript.
References
Footnotes
Contributors The article was planned and written by EL, with revisions and amendments made to subsequent drafts by PD, RC, SL and GF. PD, JB, RC, SL, GF, FM and EW conceived and implemented the study and produced the report on which this article is based. All authors approve the final version.
Funding The study was funded by the Arts and Humanities Research Council on Cultural Value (grant no. AH/L004674/1).
Competing interests None declared.
Ethics approval University of Liverpool Research Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Unpublished quantitative data are available on request. Available anonymised transcripts can also be shared, with sharing of all anonymised qualitative data possible at such time as all recordings are transcribed. Videos cannot be shared for reasons of participant confidentiality.