When doctors prescribe books to heal the mind
Can you read your way to psychological health? Britain is finding out.
LONDON — More than 350 million people worldwide suffer from depression. Fewer than half receive any treatment; even fewer have access to psychotherapy. Around the turn of the millennium, antidepressants became the most prescribed kind of drug in the United States. In the United Kingdom, 1 in 6 adults has taken one.
But what if a scientist were to discover a treatment that required minimal time and training to administer, and didn't have the side effects of drugs? In 2003, a psychiatrist in Wales became convinced that he had. Dr. Neil Frude noticed that some patients, frustrated by year-long waits for treatment, were reading up on depression in the meantime. And of the more than 100,000 self-help books in print, a handful often seemed to work.
This June, a program was launched that’s allowing National Health Service doctors across England to act upon Frude’s insight. The twist is that the books are not just being recommended, they’re being “prescribed.” If your primary care physician diagnoses you with “mild to moderate” depression, one of her options is now to scribble a title on a prescription pad. You take the torn-off sheet not to the pharmacy but to your local library, where it can be exchanged for a copy of “Overcoming Depression,” “Mind Over Mood,” or “The Feeling Good Handbook.” And depression is only one of over a dozen conditions treated. Other titles endorsed by the program include “Break Free from OCD,” “Feel the Fear and Do it Anyway,” “Getting Better Bit(e) by Bit(e),” and “How to Stop Worrying.”
The NHS's Books on Prescription program is only the highest-profile example of a broader boom in "bibliotherapy." The word is everywhere in Britain this year, although—or because—it means different things to different people. In London, a painter, a poet, and a former bookstore manager have teamed up to offer over-the-counter "bibliotherapy consultations": after being quizzed about their literary tastes and personal problems, the worried well-heeled pay 80 pounds for a customized reading list. At the Reading Agency, a charity that developed and administers Books on Prescription, a second program called Mood-Boosting Books recommends fiction and poetry. The NHS's public health and mental health budgets also fund nonprofits such as The Reader Organization, which gathers people who are unemployed, imprisoned, old, or just lonely to read poems and fiction aloud to one another.
At best, Books on Prescription looks like a win-win for both patients and book lovers. It boosts mental health while also bringing new library users in the door. Libraries loaned out NHS-approved self-help books 100,000 times in the first three months of the program; no doubt some of their borrowers must have picked up a novel or a memoir en route to the circulation desk. At worst, it's hard to see what harm the program can do. Unlike drugs, books carry no risk of side effects like weight gain, dampened libido, or nausea (unless you read in the car).
For book lovers, an organization with as much clout as the NHS would seem to be a welcome ally. Yet its initiatives raise troubling questions about why exactly a society should value reading. What's lost when a bookshelf is repurposed as a medicine cabinet—and when a therapist's job gets outsourced to the page?
In 1916, THE CLERGYMEN Samuel Crothers coined the term "bibliotherapy," positing tongue-in-cheek that "a book may be a stimulant or a sedative or an irritant or a soporific." In the intervening century, doctors, nurses, librarians, and social workers have more seriously championed "bibliopathy," "bibliocounseling," "biblioguidance," and "literatherapy"—all variations on the notion that reading can heal.
Only recently, however, have the mental health effects of one genre—self-help books—been rigorously studied. As early as 1997, a randomized trial found bibliotherapy supervised by therapists no less effective in treating unipolar depression than individual or group therapy. More surprisingly, a 2007 literature review by the same researcher found that books treated anxiety just as effectively without a therapist's guidance as with it. A 2004 meta-analysis comparing bibliotherapy for anxiety and depression to short-term talk therapy found books "as effective as professional treatment of relatively short duration."
None of this means a book can outperform a therapist, even if it can underbid him. A 2012 meta-analysis of anxiety disorders concluding that "comparing self-help with waiting list gave a significant effect size of 0.84 in favour of self-help" nevertheless cautioned that "comparison of self-help with therapist-administered treatments revealed a significant difference in favour of the latter." Translation: A book does worse than a therapist, but it's better than nothing. And in the short term, at least, nothing is what many patients get.
Books on Prescription can be understood as an extension of larger changes in psychiatry over the past few decades. For most of the 20th century, psychodynamic therapy placed more emphasis on the therapist-patient relationship than on the content of the therapist's words. More recently, insurers' interest in cutting costs and researchers' interest in protocols that can be measured and replicated have combined to nudge treatment toward short-term, standardized methods such as cognitive-behavioral therapy. Books take this trajectory to its logical conclusion. If your aim is less to help patients explore the underlying causes of their condition than to offer step-by-step instructions for managing it, then who cares whether the exercises emanate from a mouth, a manual, or even a smartphone app?
But even therapies like cognitive-behavioral therapy require the patient to feel recognized and understood by another human being. Asked how a printed page can mimic that face-to-face encounter, Frude comes up with an unexpected word: "magic." The best books give the illusion of listening and caring, he explains, because authors who are also clinicians can draw on years of experience interacting with patients to leave each reader saying "that book was about me." He does acknowledge that not every case fits books "off the peg" (or off the rack, as we say in the United States). But it's a striking metaphor to choose—one that makes psychodynamic therapy sound like a luxury good as unattainable as Savile Row tailoring.
Where Frude sees magic, a cynic might smell pragmatism. Even short-term cognitive-behavioral therapy costs more than a $24.95 hardcover. But in any case, many patients read whether or not they have the NHS's blessing. If recommended titles crowd out the misinformation that patients might otherwise stumble upon, whether in print or online, Books on Prescription will already have helped.
It's hard not to notice that Books on Prescription was developed in the same years when American universities began to offer MOOCs, or massive open online courses. Even if an online course lacks the give-and-take of a seminar, it's better than nothing. Like Books on Prescription, MOOCs scale up an activity whose face-to-face version was traditionally out of reach of the masses. Also like Books on Prescription, MOOCs create a cost-effective alternative that may eventually squeeze out personal contact even at the high end of the market.
That concern aside, it's no surprise that self-help books can help the self. That literature might help, however, is a more controversial proposition. The other half of the Reading Agency's two-pronged Reading Well initiative, Mood-Boosting Books, promotes fiction, poetry, and memoirs. Its annual list of "good reads for people who are anxious or depressed" mixes titles that represent characters experiencing anxiety or depression (Mark Haddon's "A Spot of Bother") with others calculated to combat those conditions. Some go for laughs (Sue Townsend's "The Secret Diary of Adrian Mole Aged 13¾"); others, such as "A Street Cat Named Bob" and "The Bad Dog's Diary," read like printouts of PetTube.com. Others are darker and more demanding: Reading Well anointed Alice Munro's short stories as a selection before the Nobel Prize Committee did.
The Reading Agency's endorsement of imaginative reading stops short of making scientific claims for specific titles. Its website bristles with disclaimers that the works of literature are nominated by reading groups rather than tested by scientists. Yet the charity has given Mood-Boosting Books prestige—and the NHS has put hard cash behind them as well, providing some libraries with grants to purchase the recommended works of literature along with the "prescribed" self-help titles.
I ask Judith Shipman, who runs the Mood-Boosting Books program, whether recommending books "for people who are anxious or depressed" implies that poems or novels can treat those conditions. "I don't think we could claim that they are therapy or a substitute for therapy," she hazards after a long pause. "But for those who don't quite need therapy, Mood-Boosting Books could be a nice little lift."
Today it might seem commonplace to suggest that books are good for you. In the longer view, though, the hope that both literature and practical nonfiction can cure reverses an older belief by doctors that reading could cause physical and mental illness. In 1867, one expert cautioned that taking a book to bed could "injure your eyes, your brain, your nervous system." Some social reformers proposed regulating books as if they were drugs. In 1883, the New York State Legislature debated whether to fine "any person who shall sell, loan, or give to any minor under sixteen years of age any dime novel or book of fiction, without first obtaining the written consent of the parent or guardian of such a minor." As late as 1889, one politician called fiction "moral poison."
As radio, TV, gaming, and eventually the Internet began to compete with books, though, fiction-reading came to look wholesome by comparison. Today, with only half of Americans reading any book for pleasure in a given year, reading is finding new champions from an unlikely quarter: science. This year, Science published a study concluding that reading about fictional characters increases empathy; in his 2011 book "The Better Angels of Our Nature," the psychologist Steven Pinker correlated the rise of imaginative literature with a centuries-long decline in violence. And while correlation doesn't imply causation, randomized trials have also attempted to link fiction-reading to physical health. In a 2008 study of 81 preteens, girls assigned fiction in which characters eat balanced breakfasts ended up with a lower body mass index than the control group. The Reading Well website itself cites a 2009 study that compared heart rates and muscle tension before and after various activities and found that reading is "68% better at reducing stress levels than listening to music; 100% more effective than drinking a cup of tea." The numbers may be less telling than the fact that someone would think to compare books to tea in the first place.
It's too early to predict the long-term effects of bibliotherapy programs. There's little precedent for a government to make neuroscientists and psychiatrists the arbiters of what books should be read and why. And literary critics like me recoil from reducing the value of reading to a set of health metrics. But as library budgets shrink and any text longer than 140 characters gets crowded out by audio and video, white-coated experts may be the only ones prospective readers can hear. Racing to find out what happens next, seeing the world through a character's eyes, wallowing in the play of language—all are becoming means to medical ends. Today, for an increasing number of people, the pleasures of reading require a doctor's note.
Leah Price teaches at Harvard and is the author of "How to Do Things with Books in Victorian Britain."