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Bibliotherapy: Appraisal of Evidence for Patients Diagnosed With Cancer

Article  in  Clinical Journal of Oncology Nursing · August 2018

DOI: 10.1188/18.CJON.377-380

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SUPPORTIVE CARE
An appraisal of the evidence on the
efficacy of bibliotherapy on anxiety,
distress, and coping in patients with
cancer is lacking in the literature. Bib-
liotherapy is a self-help intervention
using a variety of tools, such as self-
help workbooks, pamphlets, novels,
and audiobooks, to improve mental
health. This review identified nine
original research articles that exam-
ined bibliotherapy as an intervention
to alleviate the psychological issues
associated with a cancer diagnosis.
Data synthesis from these studies
provides preliminary evidence that
bibliotherapy is an acceptable and
beneficial adjunct therapy for patients
with cancer experiencing anxiety,
depression, and ineffective coping.
AT A GLANCE
ɔɔ Preliminary evidence shows that
patients with cancer can benefit
from bibliotherapy.
ɔɔ Stress reduction, relief of anxiety
and depression, and effective
coping are among the most
frequently patient-reported
outcomes of bibliotherapy.
ɔɔ Consistent use of the same instru-
ments to measure patient-reported
outcomes and randomized, con-
trolled trials are warranted to draw
solid conclusions and establish the
causal link between bibliotherapy
and patient-reported outcomes.
KEYWORDS
bibliotherapy; anxiety;
cancer; coping; quality of life;
breast cancer
DIGITAL OBJECT
IDENTIFIER
10.1188/18.CJON.377-380
CJON.ONS.ORG
ASSOCIATE EDITOR JOSEPH D. TARIMAN, PhD, RN, ANP-BC, FAAN
Bibliotherapy
Appraisal of evidence for patients diagnosed with cancer
Ryan Malibiran, MSN, RN, Joseph D. Tariman, PhD, RN, ANP-BC, FAAN, and Kim Amer, PhD, RN
A
36-year-old yoga trainer,
E.A., was referred to a
breast cancer specialist in
a large academic medical
center in the Midwestern
United States for further evaluation and
consultation on treatment options for her
newly diagnosed right breast cancer. Two
weeks earlier, E.A. had a routine mammo-
gram that showed a new right breast mass.
Diagnostic mammogram and ultrasound of
the right breast confirmed this mass with no
suspicious lymphadenopathy. E.A.’s right
breast mass biopsy demonstrated grade 3
infiltrating ductal carcinoma, which was
weakly estrogen receptor–positive (1%–
10%), progesterone receptor–negative, and
HER2– by immunohistochemistry and flu-
orescent in situ hybridization techniques.
The Ki-67 index of the cancer cells was
90%. A genomic test revealed a high-risk
breast cancer subtype. Magnetic resonance
imaging of the right breast showed a 3.5 cm
x 3.2 cm x 2.1 cm mass in the right breast
with no lymph node enlargement and no
cortical thickening. Positron-emission
tomography showed no metastatic disease.
E.A. appeared very anxious while waiting
for the breast cancer specialist. The oncol-
ogy nurse provided E.A. with a novel to read
to alleviate her anxiety via bibliotherapy.
Overview
Patients diagnosed with cancer often expe-
rience anxiety and distress that can affect
their overall quality of life (National Cancer
Institute, 2015). Bibliotherapy is a therapeu-
tic approach primarily used in a variety of
mental health problems, such as anxiety
and distress, in which written materials play
a central role (Glasgow & Rosen, 1978).
AUGUST 2018, VOL. 22 NO. 4  CLINICAL JOURNAL OF ONCOLOGY NURSING  377
Bibliotherapy refers to the use of any
literature that supports good mental
health and is a versatile and cost-effective
intervention often used to supplement
other types of therapy (GoodTherapy,
2016). The National Library of Medicine
(2018) defines bibliotherapy as a form
of psychotherapy in which the patient
is given carefully selected material to
read. Bibliotherapy is often used to treat
common mental health problems, such
as stress, depression, anxiety, and psy-
chological disorders (Gots, 2016). In the
hematology/oncology practice setting,
patients may have feelings of anxiety and
distress while being screened for cancer,
waiting on results of tests, receiving a
cancer diagnosis, being treated for cancer,
or worrying that the cancer will come
back. Despite the history of therapeutic
benefits of bibliotherapy in numerous non–
cancer-related health issues, such as sexual
dysfunction (van Lankveld, 1998), anxi-
ety disorders in children and adolescents
(Amer, 1999; James, Soler, & Weatherall,
2005), and depression in older adults
(Wilson, Mottram, & Vassilas, 2008), the
efficacy of bibliotherapy in alleviating
psychosocial health problems in patients
diagnosed with cancer has not been pre-
viously examined in a systematic manner.
Objectives
The purposes of this review are to appraise
the evidence on the efficacy of bibliothera-
py for alleviating anxiety, depression, and
other psychosocial outcome variables in
patients diagnosed with cancer and to de-
scribe the patient-reported psychosocial
outcomes and their measures in research
studies involving bibliotherapy.
SUPPORTIVE CARE

TABLE 1.
STUDIES ON THE EFFICACY OF BIBLIOTHERAPY IN PATIENTS WITH CANCER

STUDY DESIGN, SAMPLE, AND SETTING TOOLS AND DATA ANALYSIS FINDINGS

24-week intervention called Active Book

Club with audiobook listening, walking, and
The authors concluded that audiobooks may
supervised book club meetings. Thematic
Exploratory and descriptive study involving bring new meaning to physical activity and
Hammer et al., analysis of pre- and postintervention semi-
17 self-referred cancer survivors with various serve as a relief from individual concerns.
2017 structured interviews and self-administered
cancer diagnoses Some stories affected participants negatively,
questionnaires were used to assess mental
and there was a high dropout rate.
health and physical activity behaviors, as well
as retention, attendance, and adherence.

This study used 45 books discussing These books were found to be beneficial to
Huang et al.,
Qualitative design early-stage breast cancer written for children children and adults, cost effective, and helpful
2015
aged 3–12 years. Content analysis was used. to patients in terms of emotional expression.

Most patients reported that they found

2 guided self-help interventions via Internet
the intervention to be beneficial regarding
Krebber et al., Qualitative study with 16 patients with head or booklet were used. Perceived benefits were
learning what matters in life, being able to
2017 and neck and lung cancer derived from thematic analysis of qualitative
put things in perspective, and feeling an
interviews.
enhanced internal locus of control.

The book Milo’s Special Kite was created to

serve as a bibliotherapeutic tool for children
with terminal cancer by allowing them to Results suggest that this book may optimally
Qualitative design in children with terminal
Moccia, 2013 relate to the story character. Qualitative support children dying of cancer and their
cancer
content analysis of existing children’s books family members.
related to death was used, and researchers
measured coping.

The workbook was acceptable as an

A self-help workbook, Mastering the Art
intervention to manage stress. 17 of 18
of Coping in Good Times and Bad, was
Descriptive, qualitative study with 18 patients participants reported that they would
used. Content analysis was performed
Roberts et al., with cancer recruited from psychosocial recommend the workbook to other patients
using data-coding method. Acceptability
2016 support cancer centers of two tertiary care with cancer. The workbook reinforced
and benefits of bibliotherapy were derived
teaching hospitals in Canada existing coping skills, positive thinking,
through content analysis of qualitative data
mindfulness, and appreciation of the impor-
from interviews.
tance of relationships.

Descriptive, mixed quasiexperimental and
qualitative design in 21 patients with cancer
Schneider
(most had lymphoblastic leukemia) who
et al., 2013
were undergoing or had recently completed
treatment
The book Nikki’s Day at Chemo was devel-
oped for this study, using coping strategies
for a child diagnosed with cancer. The
intervention was provided in a patient’s home
by a caseworker. Paired-samples t tests were
used to determine the change in the Child
Outcome Rating Scale.
Perceptions of intrapersonal functioning
improved, and physiologic arousal decreased
immediately after the initial book reading. The
participants consistently recalled the specifics
of the coping strategies employed in the
book. Parent and child were empowered to
cope with cancer together.

Psychoeducational intervention program

with one-to-one therapy, group therapy, or Patients preferred the more individualized
Descriptive, qualitative study with 28 newly
Semple et al., workbook exercises; content analysis was one-to-one therapy, followed closely by
diagnosed patients with head and neck
2006 used to determine preferences for psycho- workbook exercises. Group therapy was least
cancer
educational interventions, self-esteem, and preferred.
anxiety.

The Psychosocial Intervention Programme

Quasiexperimental design in a sample of 54
patients with predetermined psychological
Semple et al.,
dysfunction; 25 participants self-selected into
2009
the experimental group, with 29 participants
in the control group.
was delivered in participants’ homes with
a minimum of 2 sessions and a maximum
of 6 sessions. Booklets were designed for
each of the 8 problem-related areas (anxiety,
depression, eating and drinking, fatigue,
appearance, speech, smoking cessation,
and finance). Questionnaires and analysis of
covariance were used to measure anxiety,
depression, coping, and quality of life with a
3-month follow-up.
Participants reported reduction in psycho-
logical distress (anxiety and depression) and
improved social functioning and quality of
life for the experimental group, which was
sustained into the 3-month follow-up period.
All participants reported that they found the
bibliotherapeutic texts to be helpful.

Note. Level of evidence for all studies was VI, except Semple et al. (2009) and Schneider et al. (2013), which were level III.

378   CLINICAL JOURNAL OF ONCOLOGY NURSING  AUGUST 2018, VOL. 22 NO. 4 CJON.ONS.ORG
Methods
This review was conducted using
Whittemore and Knafl’s (2005) inte-
grative literature review framework,
which consists of specifying the review
purpose, performing a literature search
using computerized databases, evaluat-
ing data using primary sources, analyzing
and synthesizing data, presenting the re-
sults, and arriving at a conclusion that has
evidence-based practice applications
(Whittemore & Knafl, 2005).
Integrative Literature Search
PubMed, PsycINFO®, ProQuest, and
Academic Search Complete computerized
databases were search for relevant litera-
ture. The search terms included keywords
and Medical Subject Heading (MeSH)
terms, such as bibliotherapy, anxiety, depres-
sion, coping, quality of life, and cancer. The
Boolean operators NOT and AND were
used to yield highly relevant articles. In
addition, the search was limited to peer-
reviewed articles published from 1985–2017.
Original research articles that specified
bibliotherapy as an intervention in patients
diagnosed with cancer and articles that
conveyed evidence from the opinions of
authorities or reports of expert committees
on the therapeutic effects of bibliotherapy
on patients with cancer are also included
in the final data analysis. Nine articles were
included in the final analysis.
"Bibliotherapy refers to the use of
any literature that supports good
mental health and is a versatile
and cost-effective intervention."
Data Analysis
The nine original research studies includ-
ed in the data analysis are categorized
and summarized according to bibliother-
apeutic approaches, patient-reported
outcomes, effectiveness of bibliotherapy
CJON.ONS.ORG
and level of evidence using Melnyk and TABLE 2.
Fineout-Overholt’s (2011) hierarchy of NUMBER OF STUDIES
evidence. The patient-reported outcomes USING PATIENT-REPORTED
and the tools used to measure them are OUTCOMES ASSOCIATED WITH
presented according to the highest and BIBLIOTHERAPY AND MEASURES
lowest frequency of reporting to identify USED (N = 9)
key outcomes associated with bibliothera-
py in patients with cancer. PATIENT-REPORTED
OUTCOME n MEASURE
Results Coping skills 4 CORS
Of these nine studies, six used qualitative
Anxiety 2 HADS, CORS
study design. All nine studies conclud-
ed that bibliotherapy is beneficial to Depression 2 HADS, CORS
patients with cancer (see Table 1). In ad-
Self-esteem 1 CORS
dition, bibliotherapy is primarily studied
in terms of its association with reduced Social function 1 WSAS
levels of anxiety and depression and im-
QOL 1 UW-QOL
proved coping skills (see Table 2). The
most commonly used tools to measure Interpersonal, family,
1 CORS
anxiety and depression are the Hospital school, and global QOL
Anxiety and Depression Scale (HADS) Interview
and the Child Outcome Rating Scale Self-efficacy 1
guide
(CORS). The CORS instrument is intend-
Perception of Interview
ed to measure anxiety, depression, and helpfulness
1
guide
general functioning (coping) for children
aged 6–12 years. Interview
Perception of support 1
guide
Discussion CORS—Child Outcome Rating Scale; HADS—Hospital
Anxiety and Depression Scale; QOL—quality of life;
Overall, the studies included in this review UW-QOL—University of Washington QOL questionnaire;
reported positive results. Of note, research- WSAS—Work and Social Adjustment Scale
ers have measured various patient-reported
outcomes using different measures. Most
of the outcomes measured are within the to determine the effect size of bibliothera-
psychological domain; however, there was py on these key outcomes.
Limitations
The studies that met the inclusion and ex-
clusion criteria in this review have small
sample sizes that limit the generalizability
of the findings. The inclusion and exclusion
criteria are arbitrarily determined, and they
may have introduced unintended selection
bias effect. The use of various measures
for a specific outcome presents serious
limitation in determining the strength of
heterogeneity in the outcomes measured association between bibliotherapy and its
and measures used. Future studies on therapeutic benefits. The consistent use of
bibliotherapy in patients diagnosed with standardized measures for anxiety, depres-
cancer should consistently measure key sion, and coping is recommended in future
outcomes, such as anxiety, depression, and studies to facilitate meaningful compari-
coping, and should use the same measures sons and draw solid conclusions.
AUGUST 2018, VOL. 22 NO. 4  CLINICAL JOURNAL OF ONCOLOGY NURSING  379
SUPPORTIVE CARE
Conclusion
Bibliotherapy appears to be acceptable and
beneficial in alleviating patient-reported
anxiety and depression and improving
coping skills in patients diagnosed with
cancer. Randomized, controlled trials
are lacking to establish the causal re-
lationship between bibliotherapy and
patient-reported outcomes.
Ryan Malibiran, MSN, RN, is a recent graduate,
Joseph D. Tariman, PhD, RN, ANP-BC, FAAN, is
an assistant professor, and Kim Amer, PhD, RN, is
an associate professor, all in the School of Nursing
at DePaul University in Chicago, IL. Malibiran can
be reached at malibir2@gmail.com, with copy to
CJONEditor@ons.org.
The authors take full responsibility for this content and did
not receive honoraria or disclose any relevant financial
relationships.
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