Within the medical humanities, the primary foci of interest in reading have been upon its potential to promote a more empathetic and holistic understanding of the human condition among medical practitioners1 2 and to provide new insights into conditions such as mental illness.3 Evidence of the fruitfulness of this area of activity can be seen in Gillie Bolton’s regular Opening the Word Hoard section in this journal. The therapeutic effects on patients themselves of reading fiction and poetry have, however, received less attention, although they have been recognised.4 While there are documentary accounts of practical work going on in this area, there is a dearth of research evidence supporting the therapeutic use of literature. A mapping exercise of the field of reading and health carried out by The Reading Agency for Arts Council England highlights the lack of priority given to reading-related work in the arts-in-health movement in the UK and emphasises the need to develop a sound evidence base if a strong case for reading and health is to be made.5 This paper aims to contribute to the development of this evidence base by reporting the findings of an exploratory research study set up to look at the experiences of people taking part in a community-based reading project, Get into Reading (GiR), in Merseyside, England.

READING AND HEALTH

One method of linking literature to health is “bibliotherapy”, which can be broadly defined as the use of literature to bring about therapeutic effects, usually under the guidance of a facilitator or therapist. Aiex6 offers several reasons for using bibliotherapy with an individual, including helping to develop their concept of self and encouraging honest self-appraisal; increasing their understanding of human behaviour and motivations; helping to relieve emotional or mental pressure and enabling them to see that their problem is not unique to them. Bibliotherapy originates in North America, where it is used most extensively with children and adolescents to address a wide range of issues such as divorce, the mental illness of a parent, sexual abuse, death and dying, and aggression.7^–12 Most of this work is based on the use of fiction chosen for its appropriateness to particular life situations.

In the UK, interventions referred to as “bibliotherapy” are currently being used primarily in clinical settings with adults who are experiencing mild to moderate mental health problems, such as depression13 and anxiety.14 These interventions tend to involve the use of self-help literature rather than fiction or poetry. However, over the past 10 years some UK models of bibliotherapy have emerged that do use poetry and works of fiction. This kind of bibliotherapy works by enabling the reader to identify with the characters presented to them, symbolically experiencing the problems they experience and also the solutions to those problems.8 While self-help books may address a problem directly, the use of fiction or poetry allows the patient to look at a problem, situation or state of mind in a more indirect way. As JS Mill describes in his account of being “cured” of an almost suicidal depression by reading Wordsworth, it is the emotional recognition and release that seem to be key.15

One relatively high profile project is the Reading and You Scheme, a bibliotherapy project set up by Kirklees and Calderdale Library Services in 2000 in partnership with local Primary Care Trusts.5 As well as running reading groups and other socially oriented “reader development” events, the Reading and You Scheme operates on a “prescription” basis, offering one-to-one bibliotherapy sessions to people referred by health professionals, as well as to those who have self-referred. This scheme is aimed at people experiencing mild to moderate mental health problems such as stress, anxiety and depression. As this project uses fiction and poetry, it is conceptually more closely allied to the model of bibliotherapy developed in North America than to those projects using self-help material. The element of self-referral may be crucial to the success of the scheme, as a limitation of some models of bibliotherapy that work solely through general practitioner (GP) referrals is that they depend on the symptoms of mild and moderate depression being recognised by the GP. Research estimates that only 30% to 40% of people presenting with depressive symptoms are diagnosed by their GP, with mild symptoms of depression more likely to go unrecognised.16 More fundamentally, it is estimated that nearly 50% of people with symptoms of depressive illnesses do not even consult their doctors, partly because of the known stigma associated with mental illness.17 A system of GP referrals may also require clients/patients to actively participate in a structured programme of repeated sessions that may not suit everyone who could potentially benefit, particularly vulnerable people, those from hard-to-reach groups, people with chaotic lives and people who simply do not want to commit to a weekly group or prefer a more fluid, informal model.

Delivering schemes such as the Reading and You Scheme and GiR in community settings means that they are made accessible to everyone, including people with mild to moderate symptoms of depression, enabling participants to avoid any possible stigma from being in contact with formal mental health services. This suggests that alongside formalised bibliotherapy sessions there is a need for more informal outreach reading projects within communities to reach a much wider range of people than those who present to their GPs and who may get picked up and agree to be referred.

THE STUDY

Aims

The aims of this study were to provide an insight into the observed and reported experiences of people taking part in six reading groups set up as part of the GiR project, and to understand how the groups work.

Data collection methods

As the projects were ongoing, no baseline data could be collected. From discussions with key stakeholders in the project, the research team concluded that the administration of formal questionnaires such as standardised quality-of-life or depression scales would have been inappropriate, given the informal, first-name-only nature of the projects and the particular client groups involved, which included recovering addicts.18 Qualitative research methods offered the opportunity to explore the participants’ own experiences in a non-directive and empowering way, enabling respondents to shape the research with their contributions.19 Three methods of data collection were used—stakeholder interviews, observations and a case study.

Stakeholder interviews

A joint interview was conducted with the three GiR project workers and the project director. This explored the thinking behind the project and the experiences of the project workers in running the reading groups.

Observations

A researcher (SH) attended five reading groups once each, in order to gain an understanding of the range of groups within the project and the nature of the work being done with them. Observation enhances the researcher’s ability to describe and therefore understand social phenomena that are unlikely to be captured by alternative research methods. It is particularly useful in settings such as this, where social interaction is key to understanding how the groups are experienced by all the participants, including the facilitators.20 The groups attended were a carers’ group, a group based in a drug rehabilitation centre, one based in a YMCA and two based in community libraries.

Case study

Case studies have been successfully used in health research to explore in depth specific social phenomena, and they have the advantage of being explicitly situated within a particular context.21 A third, library-based group was chosen as a case study, and between December 2005 and February 2006 SH attended and took field notes of six meetings of the group. In addition to these notes, audio recordings were made of two of the sessions. These were partially transcribed, focusing on the informal interaction that occurred during the reading of the book that the group was reading at the time (Wuthering Heights, by Emily Brontë). Unstructured interviews were conducted with six group members, as well as with the two librarians who facilitate the group. The aim of these interviews was to explore group members’ motivations for joining and staying in the group, their personal reading habits and the perceived benefits of being in the group.

Setting

The GiR project is a community reading project operating in the Wirral, in the north-west of England, whose main aims are to improve literacy, encourage library use and promote mental well-being through the use of books.22 It is run by The Reader, an outreach unit of the University of Liverpool, in partnership with a range of local agencies including Wirral Libraries, the Birkenhead and Wallasey Primary Care Trust and Job Centre Plus, and with funding from the Paul Hamlyn Foundation. The project employs three part-time project workers, all with a background in literature, and a project manager. All GiR groups meet weekly for up to 2 hours, and the facilitators and some self-selecting group members read aloud from the chosen stories, poems, novels and plays.

Participants

The research participants were all members of GiR reading groups. The project workers run reading groups with specific client groups of two to 12 people; groups have included recovering drug addicts and alcoholics, vulnerably housed men, full-time carers, lone parents and isolated elderly people. In addition, the project workers also undertake some one-to-one work.

Analysis

The audio recordings of the interviews and the observed reading group sessions were partially transcribed. The transcripts were analysed thematically, using NVivo qualitative analysis software.

FINDINGS

Reading aloud

The most significant defining characteristic of the way in which the GiR groups work is that most of the reading is done aloud during each of the weekly sessions. Although participants are free to read the texts outside the sessions, and many do, this is not required. In most of the GiR groups, the facilitators take a lead role in reading the texts, with other members taking a turn to read; but in some groups the reading is shared out more equally, with members simply taking turns to read. In the GiR reading groups, the act of reading aloud is seen both by those involved in running the project and by group members as an essential component of the project’s success. As this member of the case study group puts it from a participant’s perspective:

… it’s nice to have somebody read to you. I don’t think there’s anything nicer than sitting there listening to somebody reading to you, I find that really relaxing. It’s as though you can just let your mind wander and y’know you get all your imaginary pictures of how certain characters are, I think that enhances it. It’s as though, I don’t know, a different part of your brain is involved again. It gets you thinking a bit more ’cause you’re listening.

The additional dimension that is brought to the reading groups by reading the books aloud is explained in almost transcendental terms by one of the project workers:

It is, it’s like it’s out there, sort of, it’s not just in your head and down there, it’s out there as well and, this is going to sound a bit mad, but it is a bit like, what you’re saying about an atmosphere descending, it does feel like, this does sound crazy, it does feel like somehow the words are all spinning around you somehow and that it’s … a mood is created which we’re all part, and OK everybody might be visualising something in a different way but there is something binding as well, there is definitely something invisible and binding.

Reading the text aloud within the group setting at weekly meetings means that the GiR groups differ fundamentally from most reading groups and book clubs. Reading aloud does not seem to constitute a major component of reading group activity, although Hartley does document groups that read extracts aloud as part of their sessions (p86).23 There seems to be very little written on reading aloud with adults in this way, with most literature focusing on the benefits to children acquiring literacy skills, where both reading aloud to children and getting them to read aloud to adults are recognised as essential learning activities. Only one article was found that makes the case for reading aloud with adults: Fabish24 argues that reading aloud has educational benefits such as teaching about the relationship between spoken and written language and also creates an emotionally safe learning environment. Reading aloud, he argues, can be of value both to young children and to older children and even to college students and other adult learners. In the GiR reading group, the book acted as a powerful coalescing presence, allowing participants a sense of subjective and shared experience at the same time.

The social functions of the groups

In different ways, the groups all serve a useful social function, providing a medium through which relationships are formed between people of different ages, genders and backgrounds. The case study group is more markedly a group in which the social dimension is as important as, or even more important than, the literary one. The other groups are not so overtly social in nature, with less time given over to general chat and more of a focus upon reading. However, it is clear that strong and supportive relationships do exist between members of the groups, with concern and support shown for all members. For instance, if a regular member does not attend for a couple of weeks, other members are concerned to know why the person is not attending and to make sure that the person is well. For two of the groups, socialisation outside the forum of the meetings takes place in the form of occasional theatre visits. The YMCA and drug rehabilitation unit groups serve somewhat different functions from the others, in that they are not essentially community-based and their membership is drawn from narrow, and in a sense “captive”, client groups; therefore the social dimension is not as pronounced.

This social dimension is particularly striking in the case study group, which, over the 18 months or so of its existence, has developed a loyal core membership of about eight people, of mixed ages, predominantly women but currently with two men attending. An interest in reading is not the only (or in some cases even the primary) reason for attending the group. Three or four of those who attend are mothers of young children who see the reading group as offering an hour and a half of time for themselves in a relaxed and friendly environment, with other adults, knowing that their children are safely (and at no charge) being looked after on the premises, as this woman explains:

I’ve got three young children and I don’t get a lot of time for myself and even when I do—I usually read in bed, and usually then I’m tired and what have you. So I thought I’d come here because there’s crèche facilities and I can get an hour and a half to myself where I can sit and concentrate on books, talk about books, read books.

For two of the members of this group, both in their eighties and living alone, the group has been especially important in providing a source of companionship with people of different ages. One of these individuals is a woman who was quite isolated but was persuaded by one of the librarians to come along to the group and is now a regular member. The other elderly member is a widower who, when asked what he likes best about the group says without hesitation:

Company. I think that’s the first thing to say. Nice company. And then the interesting part is this [Wuthering Heights], what you’re doing here, and the way it’s put over by these people here [the librarians]. I think it’s very good.

This individual was invited by his daughter to come along to the group. Interestingly, two other women also come to the group with their mothers. So the group also provides a leisure activity that can be enjoyed across generations.

The therapeutic function of the groups

Some of the groups have a more obviously therapeutic function than others. In the case of the reading group based in the residential drug rehabilitation unit, the group may be seen as augmenting the work that goes on in the unit, although it is not formally integrated into a treatment programme for residents. The groups are not set up with a specific therapeutic purpose, and attendance at the group is voluntary, with a few residents attending. The session SH attended was the first after the group had restarted and was attended by three residents and one volunteer. The residents who attended seemed to be genuinely engaged with the story they were reading (The five people you meet in heaven, by Mitch Albom), and this led to one man sharing his life story with the group. This was triggered by the fact that the chapter of the book being read dealt with the protagonist’s experiences in the Second World War, which led the man to mention that he had been in the army, a key stage in the narrative of his life and how he came to be in the unit.

One of the library groups can also be seen as having a therapeutic dimension simply because it was set up with people with mental health needs specifically in mind. Again, however, there are no set therapeutic aims or outcomes that the group is seeking to achieve. Rather, it is simply there to tap into the generally accessible therapeutic effects of reading and discussing literature, guided by sensitive and skilled facilitators whose backgrounds are principally literary. To some extent the carers’ group and the YMCA group can also be considered to have a therapeutic dimension, mainly because they are aimed at distinct user groups (carers and homeless men) who may be considered to have particular emotional needs that might be partially met through reading and discussing literature with people who share similar problems.

The literary function of the groups

It is important to emphasise that the primary impetus behind GiR is an enthusiasm for literature and reading and a desire to spread this enthusiasm to others. This comes across in the project’s literature,22 in interviews with the project workers and in the groups themselves. As two of the project workers explain it:

PW1: You’ve got to love the books and love the people and think it’s worth introducing the people to the books.

PW2: And love the books in the way, in the same way that you love the people.

While some of the participants have little if any previous experience of reading literature or poetry, others in GiR have chosen to become involved because they are already active readers of literature of some kind or another. This is certainly true of the members of the case study group who were interviewed. All saw themselves as active readers before getting involved in the reading group, but what the group offered them, in literary terms, was the opportunity to expand their literary horizons and to gain confidence in reading literature that they previously thought was outside their range. For instance, one elderly man explained that he usually read war fiction and books by local authors. Another member, a young woman with 10-month-old twins, saw joining the group as providing her with the opportunity to read something other than the “cheap rubbish from Tesco’s” that she usually read. She explained that she would not have chosen to read Wuthering Heights, the book she was reading with the reading group:

… it was quite hard to get into because it’s not a book I’d ever think of picking up. It has been nice that way that you’re reading something completely different.

Another member of the case study group explained how her involvement in GiR, first as a group member and more recently as a volunteer mentor, had brought her to read books she would never otherwise have read:

I’d’ve never, never, ever have done Dickens, it was too big a book for starters. Bleak House, I’d’ve thought no, I couldn’t do that, I haven’t got time to do that, or I would never have picked up any of the classics. But it was just [name of facilitator] suggested Thomas Hardy and I thought I’ll give it a go, and I really, really, enjoyed it. I definitely want to do more of that.

First and foremost, then, the aim of the project is to read literature and to encourage the reading of literature that is of some literary merit, with the primary objective of enjoying and responding emotionally to literature. Any social or therapeutic benefits that arise from the reading of that literature are in an important sense secondary. This resonates with Long’s historical analysis of reading groups as being primarily motivated by the pleasure of reading, rather than any other social objective.25 Where the success of a project that is primarily therapeutic might rest on the skill of the therapist in guiding the client to a state of insight or self-awareness, the success of GiR (and perhaps other bibliotherapy projects) rests on the potential of the literature itself to mediate that process. That is not to say that the facilitators/therapists who guide the process are not also skilled and that their role is not important, but the crucial factor is the use of literature as a medium of communication where the literature, to an important extent, has a therapeutic power of its own. Furthermore, with the GiR groups, the process of reading the literature aloud in the shared space of the group adds another dimension to this process of mediation.

DISCUSSION

Projects that focus on bringing together people and works of literature are essentially formalising a process that is innate, that is the encounter between reader and text. It harnesses the power of reading as a cognitive process, steering the reader/patient towards some kind of insight or new understanding. The findings from this study suggest that both the participants in the groups and the facilitators were to some extent aware of the power of reading particular works of literature aloud and participating in a shared experience. Work undertaken by Keith Oatley and colleagues in Toronto that looks at the way readers relate to texts appears to be of particular relevance in understanding the cognitive dimension of reading.26 27 Of particular interest is Oatley’s paper, which draws on the literary theory of Bakhtin, arguing that the reading of fiction involves the reader being encouraged, through the use of different literary techniques, to take different positions on a spectrum from observation to identification at different points in the text.26

Oatley argues that this spectrum is comparable to Scheff’s scale of aesthetic distance, which runs from overdistanced to underdistanced.28 The overdistanced position corresponds to a spectator stance in which emotional issues are kept from encroaching on the self, while the underdistanced stance corresponds to the stance of identification in which the readers experience emotions as if they were their own. Oatley goes on to argue that in order to derive insights from a story, the reader should both experience the emotions contained in it and be able to reflect on them. He suggests that people who are inclined to avoid emotions in real life might learn how to be less avoidant by reading literature that is emotionally intense and underdistanced. Concomitantly, he proposes that people who are inclined to be preoccupied with relationships and thus emotionally vulnerable should read literature that is more emotionally distanced, leading them to reflect on as well as experience emotions.

The findings from this study suggest that while both the choice of literature and the shared act of reading aloud significantly shape the experience of the participants in GiR, the way in which the project is set up is critical to its success. Participants valued the fact that they could turn up at a session without having had to have read the book in advance, and even people who had gone on to read the book at home were still coming back to share the experience of being part of the group and reading the text with other group members. Missed sessions did not appear to affect the willingness of people to rejoin the group, as they were quickly able to pick up where the group had got to, thanks in part to the skills of the facilitator and the active encouragement of the rest of the group. Participation in the groups and within each of the group sessions was entirely voluntary, and while some chose to engage actively, others did not. This feature distinguishes the GiR project somewhat from the more mainstream bibliotherapy projects that require regular attendance at sessions, and it potentially increases the project’s appeal to different sections of the community.

The work of the GiR project differs from the bibliotherapy sessions organised as part of primary care, in that there are no therapeutic goals for each individual, no “work” outside the group, and so all the activities take place within the group, as a shared experience between group members. However, despite the lack of specific therapeutic goals, it is clear from both the observations and the interviews that the GiR groups have significant potential to increase feelings of well-being in participants. Studies in the treatment of depression have found that people with depression often prefer a talking therapy such as counselling to taking medicines, and around a third of participants in one study believed that it would be more effective than a prescription of antidepressants.29 Research with depressed women has found that they value the opportunity to take an active role in the treatment and management of their condition and that they find social activities, such as sharing their experiences as part of a group, or taking time to read books, to be an important part of the healing process.30^–32

Although there is clearly a role for different approaches to the treatment of depression (medication, talking therapies and therapeutic groups), research with GPs suggests that they are more likely to offer patients a course of antidepressants than counselling, due partly to the lack of appropriately trained mental health workers but also partly to GPs’ own ideas of how depression should be managed.33 Clearly, more work needs to be done on the possible benefits of reading in community settings, with a greater emphasis on the possible therapeutic benefits of reading groups as well as their capacity to improve the sense of general well-being of all those who participate in them.