Bibliotherapy: A Critique of the Literature*
BY ARMANDO R. FAVAZZA
ABSTRACT
Most of the literature on bibliotherapy has been
nonscientific, because of the too broad use of the
term "bibliotherapy." The author proposes, for the
sake of clarification in the literature, that "biblio-
therapy" be defined as a program of selected ac-
tivity involving reading materials which is planned,
conducted, and controlled under the guidance of a
physician as treatment for psychiatric patients and
which uses, if needed, the assistance of a trained
librarian. Bibliotherapy, then, falls into three cate-
gories: books prescribed for a patient, books se-
lected by a patient, and group discussion of books.
Bibliotherapy may be helpful by facilitating abre-
action, projection, narcissistic gratification, ver-
balization, constructive thinking between inter-
views, and reinforcement of social and cultural
patterns. Bibliotherapy is probably indicated in
self-motivated neurotic patients who ask for help-
ful reading materials. Bibliotherapy offers no
panacea, but with proper scientific study may help
many patients.
COVILLE, a psychologist, wrote in 1960 that
84 percent of the literature on bibliotherapy
(more than 400 articles) was written by non-
medical authors (1). Because of their nonmedi-
cal presentation, most of these articles do not
appeal to the intellect of a physician. But even
many articles written by physicians concerning
bibliotherapy would not appeal (and have not)
to their colleagues. The truth of the matter is
that the vast majority of the literature on bib-
liotherapy is repetitiously shallow, anecdotal,
unscientific, conjectural, confusing, propagan-
distic, and static. The librarian states his pre-
eminence in bibliotherapy, the social worker
his, the psychologist his, the physician his, the
nurse hers-according to which journal one
* Completed during a psychiatric research clerk-
ship at the Department of Neurology and Psychia-
try of the University of Virginia School of Medi-
cine.
138
Senzior Medical Student
School of Medicinie
University of Virginia
Clharlottesville, Virginia
happens to read. What Bryan, one of the best
commentators, wrote in 1939 holds true today:
So far most of the work in bibliotherapy seems
to be based on untested assumptions rather than
upon systematic scientific observation and con-
trolled experimentation.... If we are to have a
science of bibliotherapy we must pass beyond the
anecdotal stage in formulating principles and pro-
ceed to scientific experimentation (2).
The Veterans Administration in its planning
letters has exhorted and encouraged its staff
members to carry out research projects con-
cerning bibliotherapy (3, 4). It is incredible that
so many articles on bibliotherapy have been
published, when the Veterans Administration
lists over thirty-five basic questions which have
not been answered. A few of these basic ques-
tions are: (1) To what extent can bibliotherapy
help the patient understand his own psycho-
logical and physiological reaction to frustration
and conflict? (2) To what extent can biblio-
therapy help the patient verbalize problems
otherwise difficult to discuss because of fear,
shame, or guilt? (3) Can bibliotherapy save time
in the treatment process? (4) What benefit, if
any, can be derived by neuropsychiatric patients
from reading books on mental health subjects?
(4) To what extent is it important for patients
"to keep in touch with the outside world" via
newspapers, magazines, and books?
The listed questions were among those asked
in December 1956. In June 1958, in another
planning letter (3), several field stations reported
their results. In one project the research report
states that in order to study the reading habits
of psychiatric patients a random selection of
patients' borrower's cards was made, the type of
book listed and categorized, and results tabu-
lated. The authors evidently never asked the
patients if they read the books! The other
 BIBLIOTHERAPY: THE LITERATURE
projects listed had similar deficiencies, and what
was written in the conclusion of one project is
applicable to them all: "Certain methodological
shortcomings limit the generalizability (sic) of
the findings. Future investigations might seek to
remedy these flaws."
An initial problem is the definition of the
word "bibliotherapy." Quite simply it means
"therapy utilizing books." But what does "ther-
apy" mean, and for whom is treatment intended?
Only some authors trouble to distinguish be-
tween medical and psychiatric patients when
discussing bibliotherapy; thus we read about
strange things under the label of "bibliother-
apy." Examples of comments follow:
The convalescent period offers great possibilities
for improving the mind and raising the standard of
appreciation of literature (5).
Literature may indirectly mean therapy to the
patients by what it has to provide the doctor (6).
The author goes on to relate how Edmund Wil-
son's Menmoirs of Hecate County helped him to
understand a patient's problems:
Start the patient planning for something he can
do when he is better, e.g., redecorate a home, or
"how to attract birds" (7).
A book, then, if it is the right book, can do a
great deal. It can stimulate to pleasant and health-
ful mental activity; it can calm; it can occupy; it
can divert; it can strengthen; it can influence; it
can reveal Christ; it can bring a soul back to
Christ (8).
Let us take courage from the realization that in
books where other minds speak to us, console and
even reveal their souls to us, invaluable friends,
counselors, and teachers are thereby given to us.
Every parent, every teacher, every librarian, there-
fore, who puts a good book into the hands of
another is using a mild form of bibliotherapy (9).
The following discusses a schizophrenic:
But, undoubtedly, it will renew his sense of confi-
dence, of mastery, of reality once again to get a
grasp on his environment to the extent of under-
standing the salient events occurring since he lost
interest in the world. Such magazines as Time,
Life and Reader's Digest will serve this need (10).
While we might sympathize with some of the
preceding material, while semantically it might
be about bibliotherapy, we should not call its
content bibliotherapy if we are ever to develop
a scientific discipline. It is certain that a patient
in a hospital is bored and often disheartened.
Yet if we place a television in his room to help
139
dispel his boredom and perhaps even cheer him
we do not call the action "videotherapy." Put-
ting flowers into a patient's room is not "hor-
ticulturotherapy," even though it may help the
patient. It is important, although not extremely
so, that a patient be diverted, interested, content.
This goal is worthy of future study and falls
within the librarian's province, but let us not
call it "bibliotherapy." Even should a physician
request that a patient read a book, say, about
diabetes so that he may better understand his
problem, let us not call this "bibliotherapy"
either. "Reading guidance" might be a less con-
fusing term.
The author proposes, purely for the sake of
clarification in the literature, that "bibliother-
apy" be defined as "a program of selected activ-
ity involving reading materials, planned, con-
ducted and controlled under the guidance of a
physician as treatment for psychiatric patients
and utilizing, if needed, the assistance of a
trained librarian" (this definition is modified
from one proposed by Shrodes and quoted by
Kinney (11)). By understanding bibliotherapy in
the context of psychiatry we can focus more
clearly on the problems.
Bibliotherapy, then, falls into three cate-
gories: (1) individual books prescribed for a
patient, (2) books selected by a patient for dis-
cussion with the physician, and (3) group discus-
sion of books.
Bogard (12) would call bibliotherapy the uti-
lization of the library for a task-oriented expe-
rience. For example:
The patient's participation need not be directed
to the context of books, or to the selection of new
acquisitions, but more towards an active participa-
tion in the running of an efficient service organiza-
tion.
To call this activity "bibliotherapy" simply be-
cause it takes place in a library means that if
work activity takes place in a kitchen we should
call it "kitchen-therapy," in a garden, "garden-
therapy" (see Hirsch (13)). Obviously what is
important is the activity and not the location;
thus Bogard's use of the term "bibliotherapy" is
specious.
Alston (14) lists some reasons why, on face
value, bibliotherapy might be useful: books pro-
vide a broad coverage of every aspect of the
human situation, books can be referred to time
and again, many people can approach a book
140 ARMANDO R. FAVAZZA
with minimal defensiveness and maximal acces-
sibility, and for many people the written word
has an exceptional authority and authenticity.
Menninger lists four ways in which biblio-
therapy can be of help (15): (1) The patient may
identify with a character or an experience with
a subsequent abreaction, especially in fiction
where a hero overcomes a problem. (2) Through
the use of projection the patient may experience
a vicarious expression of traits. (3) The patient
may make comparisons between the author's
ideas and his own. (4) The patient may achieve
narcissistic gratification; e.g., fantasy expression
or ego strengthening due to increased knowl-
edge.
Gottschalk (16) feels bibliotherapy may be
helpful as follows: (1) The patient may better
understand his reactions to frustration. (2) The
patient may better understand medical terminol-
ogy. (3) The patient may verbalize his problems
better when he realizes that other persons have
had the same problem. (4) The patient may
think more constructively between interviews.
(5) It may reinforce, by precept and example, a
social and cultural pattern of behavior and in-
hibit infantile behavior patterns. (6) It may stim-
ulate the patient's imagination and enlarge his
sphere of interests.
Appel (17) writes that bibliotherapy may be
advised: (1) in an attempt to extravert the pa-
tient and arouse his interests in something out-
side himself, (2) to arouse interest in and ac-
quaintance with external reality, (3) to effect a
controlled release (abreaction) of unconscious
processes, (4) to offer opportunities for identi-
fication and compensation, (5) to help the pa-
tient develop a clarification of his difficulties
and contribute to the development of "insight"
into his condition, (6) to implement the expe-
rience of others in effecting a cure, and (7) to
extend the period of the therapeutic conference
when the patient cannot be seeing the doctor.
It might be stated that the reported ways in
which bibliotherapy may help are based on
rather commonsense psychiatric arguments with
a minimum of scientific experimentation and
clinical case study. Gottschalk (16) and Schneck
(18), for example, report only a few cases.
Many other authors dealing with the subject
simply state "It has been my experience that
I. refer briefly to some personal successes,
and proceed to make hypotheses and dictums.
What patients are candidates for bibliother-
apy? Gottschalk (16) feels those patients are
candidates who actively seek psychotherapy,
who have established reading habits, and who
have mild neuroses. Menninger (15) states that
bibliotherapy is not for psychotics, obsessive-
compulsive neurotics, patients with an anxiety
state, or patients undergoing psychoanalysis. He
also states that "it [bibliotherapy] has often been
helpful for the relatives of patients." Delaney
(19) reported use of bibliotherapy in an alco-
holic antabuse clinic. Appel (17) feels that bib-
liotherapy may be useful in any patient who is
self-motivated and asks his physician for read-
ing matter which will be helpful.
Having determined the advisability of bib-
liotherapy for a patient, how should the physi-
cian then proceed? Most of the intelligent liter-
ature seems to agree with Hirsch's statement:
As far as . .. recommending specific books for
reading, I personally do it very rarely.... How-
ever, I think books could be, and are, recommended
often to an advantage (13).
One method, then, would be to let a moti-
vated patient read what he will and then discuss
the book with his physician. Aside from the
previously listed ways in which reading may
help, the author of this paper, in a study which
will be published shortly, has indicated that in
depressed and schizophrenic patients active
reading may indicate a return towards normal-
ity. Menninger also reported:
We have repeatedly been able to see a close
parallelism between the recovery or the improve-
ment of the patient and his renewed interest in
books (15).
Appel feels that "the prescription of reading
matter must be a highly individualized proce-
dure if it is to be successful" (17). He then out-
lines an order of psychiatric reading which he
found effective. He starts the patient with Osler's
Way of Life (1932) as a book offering a "whole-
some philosophy of life." Then he advises Rigg's
Just Nerves (1922), then Strecker and Appel's
Discovering Ourselves (1931). This is followed
by Sayle's The Probletm Child at Home (1928)
and then Thom's Normiial Youth and Its Every-
day Problemns (1932). When family relation-
ships are important, he advises Levy and Mon-
roe's The Happy Famnily (1941), then Horney's
The Neurotic Personality of Our Time (1937).
A historical perspective is added by advising
Robinson's Mind in the Making (1921). A note
 BIBLIOTHERAPY: THE LITERATURE
of optimism is added in Edman's Candle in the
Dark (1939).
Moore (20) has described quite well his ex-
periences in bibliotherapy with children and
recommends specific titles.
Sadler (21) has described a "reading cure."
He uses mathematics as a memory developer
and poetry as "a healing balm for the soul." He
requires his patients to memorize poetry, read
the Bible, do arithmetical problems, read novels,
and read books on nature study. He also pro-
poses a full study program in which the patient
must write a thesis answering the questions:
What is the matter with me? How did I get that
way? What am I going to do about it? The pa-
tient then proceeds into "post-graduate" train-
ing; i.e., "the finer points of personal, domestic,
social, economic and cosmic adjustment of the
personality to the realities of the world and of
the universe."
Delaney (19) uses group therapy in her alco-
holic antabuse clinic. The books which her
group discusses are: Anderson's The Other Side
of the Bottle; Sherman's You Can Stop Drink-
ing; Maine's If a Man Be Mad; Mann's Primer
on Alcoholism; Lovell's Hope and Help for the
Alcoholic; and Town's Habits That Handicap.
Bass (22) gives a too brief account of a "great
books" program for psychiatric patients at New
York's Mount Sinai Hospital. This program has
appeal because the "great" books discussed usu-
ally touch many aspects of the human situa-
tion in depth.
Powell, Stone, and Frank (23) have de-
scribed a similar great books discussion group
therapy plan and found that in some patients
the reading led to better group participation
and decreased anxiety.
Obviously, what has been scientifically done
with bibliotherapy has just scratched the sur-
face. After sixty years of article writing, the
potential of bibliotherapy is still unknown.
Certainly bibliotherapy offers no panacea, but
hopefully it will take its place in the therapeu-
tic regimen open to the psychiatrist. Biblio-
therapy is inexpensive, available to everyone,
and simple. It will cure no one. It may help
many.
REFERENCES
(Important references are indicated by an asterisk.)
1. COVILLE, W. J. Bibliotherapy, some practical
considerations. Hosp. Progr. 41: 138-142,
Apr. 1960.
141
*2. BRYAN, A. T. Can there be a science of
bibliotherapy? Libr. J. 64: 773-776, Oct.
1939.
3. Veterans Administration Planning Letter No.
56-124, Dec. 31, 1956.
4. Veterans Administration Planning Letter No.
58-48,June 11, 1958.
5. CLARKE, E. K. Books for the convalescent.
Libr. J. 62: 893-895, Dec. 1937.
6. SJOGREN, H. Patients and books. Libr. Ass.
Rec. 56: 342-346, 1954.
7. BURKET, R. When books are therapy. Wilson
Libr. Bull. 29: 450-452, Feb. 1955.
8. DE LISLE, M. Catholic books in Catholic
hospitals. Catholic Libr. World 14: 110-
117, 1943.
9. LUCILE, SISTER A. Bibliotherapy: A counsel-
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10. MASCARINO, E., AND GOODE, D. Reading as a
psychological aid in the hypoglycemic treat-
ment of schizophrenia. Med. Bull. Veterans
Admin. 17: 61-65, July 1940.
* 11. KINNEY, M. The Patient's Library in a Psy-
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Annual Spring Meeting of the Committee
on Patient's Libraries, April 28, 1965.
12. BOGARD, H. Bibliotherapy-For Whom and
by Whom. A paper presented at the Annual
Spring Meeting of the Committee on Pa-
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* 13. HIRSCH, L. Bibliotherapy with neuropsychi-
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*14. ALSTON, E. Bibliotherapy and psychotherapy.
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*15. MENNINGER, W. C. Bibliotherapy. Bull. Men-
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*16. GOTTSCHALK, L. A. Bibliotherapy as an ad-
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* 17. APPEL, K. Psychiatric therapy; explanatory or
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bibliotherapy. In: Hunt, J. M. V., ed. Per-
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York, Ronald Press, 1944, vol. 2, p. 1128-
1133.
18. SCHNECK, J. M. Bibliotherapy for neuropsy-
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19. DELANEY, S. Bibliotherapy for patients in
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143, Oct. 1955.
*20. MOORE, T. V. In: KIRCHER, C. J. Character
Formation Through Books, a Bibliography.
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21. SADLER, W. Modern Psychiatry. St. Louis,
Mosby, 1945, p. 780-789.
22. BASS, A. Great books are good treatment.
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