Bratislava, Slovakia
The article analyses usefulness of the literary art from the point of view of the artistic language devices used in it as a potential therapeutic tool in medical education. It is intended for experts who are interested in bibliotherapy and imagination as tools for mobilizing person's internal healing powers to support their health and well-being.
literary art, literary tools, genres, bibliotherapy, health care, therapeutic education
INTRODUCTION
To develop the competences of the patient/client to live their life, develop their potential and solve their problems more or less associated with the disease is an important part of health care or health support process. It mainly consists of formation and strengthening of self-competences like self-awareness, self-reflection, self-evaluation, self-confidence, self-support, self-respect… which we could collectively call metacognitive skills that are necessary to complete certain developmental tasks or in the healing process.
For more than 45 years, university students in Slovakia have had an opportunity to study and develop how to help others with such challenges in a five-year long study program of therapeutic pedagogy in both master's and bachelor's degrees. Therapeutic pedagogy represents integration of therapeutic and educational efforts. According to the definition of the professional guarantor of this study program at the Faculty of Education of the Comenius University in Bratislava, Prof. Marta Horňáková from 1999, “therapeutic pedagogy is a pedagogy that deals with diagnosis, education and therapy of persons whose situation is so complicated by adverse life circumstances (educational, health, social, etc.) that they cannot lead an age-appropriate way of life and apply adequately to their abilities” [1].
When developing these competencies, therapeutic pedagogues use movement, various jobs, individual, group and community creative activities (within these they use the elements of art therapy, music therapy, psychomotor/movement and dance therapy, play therapy, bibliotherapy, dramatherapy, occupational therapy and family therapy) in their work with patients or clients. It is broadly focused in terms of age - therapeutic and pedagogical action can be devoted to both children and adults, including seniors, as well as from the point of view of client's possible problems, whether they are healthy (developmental tasks) or sick, or after an illness (primary, secondary, tertiary prevention). For the purpose of assistance, individual, group, community activities or therapeutic-pedagogical educational programs are designed to meet the needs of the patient/client or the group. Bibliotherapy (therapy using the literary art) is one of the study subjects included in the Therapeutic Pedagogy university study program. According to the therapeutic-pedagogical definition of bibliotherapy, was created in 1995 by the author of the first concept of this study subject at the Comenius University in Bratislava, Doc. Katarína Majzlanová [2], “therapeutic-pedagogically oriented bibliotherapy is understood as a planned, purposeful and systematic therapeutic-educational influence through individual components of literary art on health-endangered, impaired or disabled individuals.” In this context, let's just remark that in the context of storytelling, which is also an important part of bibliotherapy, we use this definition more broadly today – that means applying any forms of verbal art - even those not recorded in writing.
Regarding the method of work, we can say that in this therapeutic-pedagogical oriented bibliotherapy we include work with words/sounds or sentences, as well as independent reading by oneself, which is either remote or in the presence of a therapist accompanied by a trained professional, but also group aloud reading of literary works, chain reading, artistic presentation, but also the already mentioned storytelling and work with various types of audiobooks - especially with clients who have some reading problems, but maybe they like literature, but also creative writing of therapeutic diaries, therapeutic letters, own literary works, etc..
LITERARY GENRES IN BIBLIOTHERAPY
A/ Non-fiction literature
In bibliotherapy, we apply various literary genres from non-fiction, as well as fiction. A special kind of so-called self-help books is 1. non-fiction literature written by professionals (usually by psychologists, psychotherapists or teachers) in a popular-educational way and tries to convey to readers an understanding of life situations, relationships and problems, in this group of self-help books we also include 2. children's literature that contains instructions for adults - whether for parents, educators, teachers or therapists, how to work with the book, how to read it, or how to work with the child when this story or literature is read, how to react to the child's emotions after reading, etc. [3]
When it comes to medical contexts, it can be said in general, that the application of bibliotherapy is currently the most sophisticated in the issue of depression treatment. For example, recently, on June 29, 2022, an international standard of the National Institute for Health and Healthcare Excellence was published, which - interestingly - also specifically addresses the use of self-help books in the treatment of depression. It recommends that self-help books should be used initially for milder forms of depression at the beginning of the therapy process, but with more severe forms only at the end of it – that is, only when drug treatment, in-depth psychotherapy, etc., have taken place [4] as part of a better understanding of the problem but also anchoring the newly acquired competences in the new life situation, during the final phase of therapy, or even after leaving for home care, non-fiction/factual literature in the form of self-help books is recommended. A specific characteristic feature of this type of self-help book publications is that they help to understand the problem - the rational component of the personality is more affected.
And maybe it will be surprising, but among the non-fiction genres used in bibliotherapy we also include journalistic genres, such as news and reportage in particular, but also others - and it is even possible to draw attention to the fact that in this kind of non-fiction literature in connection with the potential of therapeutic-educational bibliotherapy goals we can also include creation of family chronicles, family newspapers, which can also be created in a very inspiring way of joint group, community or individual work.
B/ Fiction literature
A different kind of literature used in therapeutic process is fiction, where it is already implicit from the basic characteristics of individual literary genres how they could and should be worked with therapeutically and educationally. While lyric poetry is focused on conveying significant sensual experiences, feelings, impressions or moods and moods are expressed by poetic tools of expression mainly in a bound rhythmized form of speech, in epics the plot is important - temporal sequence and description of the course of events; there is a certain function where the author is often represented by a narrator, who can also be effectively worked with in therapy. This also partly includes drama, which is based on a dialogic form of direct speech between characters, where it is a text intended for dramatization, and where other dramatic artistic tools are also used, which, however, falls more into the field of drama therapy and therefore we don't mention it here anymore.
Depending on individual literary genres, we recognize several more subspecies or subcategories of bibliotherapy, such as paremiological therapy - which is therapy using various proverbs or sayings that belong more to the heritage of folk culture, it can also be work with aphorisms and sentences, there is also poetotherapy, fairy tale therapy, narrative therapy as a reconstruction and rewriting of one's own personal story, the story of illness and the like, but also hagiotherapy, which is therapy using religious texts [2].
In case of fiction - compared to self-help books or non-fiction literature in general, it is mainly about acting on the emotional component - that is, emotions, feelings and higher feelings and values, possibly sometimes also spirituality as part of therapeutic education.
In this context, the findings made by the authors Starker and Rubin, mediated by the authors Pardeck and Pardeck in 1998 are certainly interesting too, - that cognitive-behavioral oriented therapists prefer working with self-help literature, while psychodynamic oriented therapists like to work more with fiction [5].
However, the choice and use naturally does not depend only on the preferences of the therapist and should mainly reflect the interests and preferences of the patient/client and the identified therapeutic goals. If the development of the rational component of knowledge is important - understanding the problem, pattern of behavior, consolidation of knowledge, new coping strategies - non-fiction literature is predominantly used for this. When it comes to development of client's emotionality, so that they need not only to understand, but also to feel and develop values and attitudes - we prefer working with fiction.
At the same time, we are always aware of one important thing, that pedagogical action is the most effective, which is therefore a matter of the therapeutic work itself during therapy, when the intellect, emotions and feelings are simultaneously affected – and in general, especially higher feelings: feeling the good, wisdom, beautiful, goodness, humanity etc., that is, value orientation.
MEANINGFULNESS OF BEING AND IMAGINATION IMPORTANT PARTS OF THERAPEUTIC EDUCATION AND BIBLIOTHERAPY
In this context, we chose some quotes from the two literary awards-winning publication Behind the Secret of Fairy Tales (1975, 1976) by psychologist and psychoanalyst Bruno Bettelheim, who worked with children for many years. He is the author of the following very interesting quotes in connection with fiction, which are definitely worth attention [6]:
For example, he stated that if "children are brought up in such way that life gives them meaning, they do not need any other special help (p. 10). The ability to find meaning in one's own life and in the life around is best conveyed by literature (p. 10); for children, folk tales and modern fairy tales which contain both obvious and hidden meanings, transfer the unconscious content to the conscious mind in a safe way and allow manipulation of it (author's note on imagination), the moral outcome is only indicated in them and thus gives freedom of creation of own solution model (p. 13)."
And finally, there is one wonderful quote from the author, who draws attention to the fact that not only the literature read, but also his knowledge acquired on the basis of many years of professional experience is interesting in connection with storytelling as part of bibliotherapy experiences - when it comes to the therapeutic effect, he claims that "It is more healing to have a story told to you than to just read it, or have it read to you” (p. 37).
Imagination plays an important role in this. When working with fiction, the insight into the problem and the solution of the problem through, for example, a literary hero in the text is safe in that it allows the externalisation of the problem.
From safety, the child can project his/her own characteristics or someone from the environment onto the protagonist, or to recognize them in them while maintaining a safe distance, but with an alert awareness, to watch how the protagonist deals with the problem and allow themselves the freedom of their own solution. So that externalisation is very helpful. Vigilant manipulation of potentially emotionally burdensome content that is expressed in a hidden form (metaphors, symbols, repetitive patterns) is safe and thus enables distance, facilitates positive reframing and the creation of one's own, new model of experience or behavior.
The same thing that is true for children is essentially true for adults, too: allowing reframing is important so that a person can admit that a given situation can be looked at in a different way, which also allows them to admit that they could act differently.
A beautiful example of reframing and a new point of view, even a new vision and regardless of the fact that the author himself actually had no formal medical or psychological training and that's actually fascinating that he came up with it as a writer and conveyed it through a story without any for that purpose acquired education - so we can actually find a guide to the individual stages of therapeutic change in Dostoevsky's work The Dream of a Ridiculous Man.
Together with our colleagues - Dr. Solárová from the First Acupuncture Clinic dr. Solár in Šamorín from Slovakia and Mr. Sturcz, a literature teacher, school speech therapist and a dubbing actor from Hungary, we also analysed this interesting short story from the point of view of its therapeutic potential in a separate article that was published last year in 2022 in the Philologia journal [7].
Part of this analysis is about how Dostoevsky himself accompanies the individual phases of therapeutic change so that the old reality can be replaced by a new one; by the fact that these two realities – the old and the new one are present in the story for a certain time simultaneously as uplifting images and feelings of the new world mediated by the images that Dostoevsky describes in his contribution - feelings of beauty, joy, happiness that can be relived repeatedly, for example by means of repeated reading of this work and perhaps at the same time be inspired by this, that in such a way of admitting a new vision, reframing the situation, admitting a new reality, through them it is actually possible to get closer to it.
And maybe to start living it. When you re-read this work - I have no doubt that some of you are familiar with it - you may be able to identify in it the concepts of the Higher Self - the spiritual Self that Roberto Assagioli dealt with, or the concepts of the Wise-Old Man/Wise-Old Mother, of Carl Gustav Jung, which Dostoevsky expressed in the work, that can also be helpful to the readers in modelling their life reality, for example, in conditions changed by illness and the like. However, the point is that they admit this possibility.
LINGUISTIC TOOLS IN THE BIBLIOTHERAPY FORMS OF STORYTELLING, READING AND WRITING
For both adults and children, in addition to reading material or spoken material, we also have the writing of therapeutic diaries, therapeutic letters and notices and reports. We will approach these mainly from the point of view of the linguistic tools that are used. In case of therapeutic diaries, which are always written in the first person singular - I - the aim is to relieve oneself of potentially emotionally burdensome content by putting it on paper, or using technical means in another way, but in general, handwriting is recommended for this purpose. However, at the same time, people should be encouraged to "materialize the positive" in this way, so that they can notice it or relive it.
Similar to the writing of therapy diaries, the rules of which are mentioned in detail by Rainwater (1993) and Pennebaker (2013) in their publications [8, 9], as we wrote about it too [10], writing of therapy letters also has its own rules characterised by writing in the 2nd person singular – YOU. That is, directly addressing another person whom the matter being addressed concerns, expressing the content through pen and paper. [11]
It is mostly used in situations where simply postponing a problem or processing it through a journal in the 1st person singular is not enough and it is necessary to address the addressee directly, whether it is a living or non-living person, or a fictitious person, or even an illness - it is possible to conduct a dialogue with one's illness as a personified quality through pen and paper – to write to the person a letter and open a new perspective, enable abreaction or catharsis. Since the letter is usually not sent, it is also possible to offer to write an answer as if from that person back to the author of the letter, it is possible to create and write what the answer might be that the patient or client would need to hear or know in order to be relieved, and this enhances the healing process [11].
And finally, there is writing in the 3rd person singular – that is, "IT/THAT", from the position of an observer, when it is possible to detach even better from emotionally burdensome contents, when it is possible to write about a real event as a narrator/reporter/disinterested observer and thereby gain a different perspective and a new knowledge important for potential reaction. This writing strategy allows distance from the problem; at the end of the therapy, it is suitable for example, for anchoring the newly learned, repeating, strengthening the new and newly known.
Reading and writing/processing of the experienced can be carried out in the framework of therapeutic-pedagogically oriented bibliotherapy in the already known individual or group form (with homogeneous groups with different problems, or heterogeneous, where both the healthy and the sick are together, or with the involvement of family members or caregivers within the family or community therapy), and recently also in a rapidly developing mass form used by computer networks, as well as targeted educational-therapeutic individual and group as part of telemedicine.
THERAPEUTIC RELATIONSHIP
However, what is important here is really the emphasis on interactivity. In bibliotherapy, as we talk about it here, it is necessary to respect that if it is to be bibliotherapy, a therapeutic relationship of mutual trust should be created between the therapist and the patient/client, based on communication, support, mutual discussion not only of the literary work (literary work is often only a gateway to get to the client's problem or developmental challenges they need to address, it is a way to get to potential solutions of concerns and life challenges related or unrelated to the illness) and also to accompany the client/patient with the therapist during the therapy process.
In their works [8, 9], Janette Rainwater (1993) and James W. Pannebaker (2013) defined the roles of the therapist during the therapy process: They should be a safe person to share content with, a guide to self-discovery and personal development, a catalyst for processing content that has not yet been processed/unnoticed, a helper when formulating priorities, scaling the meaning before and after making a change, asking auxiliary questions, what did the client/patient notice as different/new - facts, senses, feelings, relationships, body perceptions,... what new did they learn... what would they need. To strengthen the effect, an eclectic approach is also possible, allowing the synergistic effect of several arts - dance, music, visual, if the person needs it. It is supposed to act as a regulator of "overanalysis", which does not bring constructive solutions for the life of the individual.
In his works [9], where he deals with writing of therapeutic diaries, Pennebaker also reports on the results of studies by other authors, according to which therapist-guided engagement with emotionally burdensome content or trauma caused not only measurable psychological changes (in the form of immediate and long-term changes in mood, experience and behavior) such as fewer depressive symptoms, reduced anxiety, individuals felt calmer, more open, friendlier, more accepting of others, happier, more aware, more participatory, smarter, but also measurable physical changes - especially in the area of the immune system and other medical values.
The most interesting information from this author is that such accompanied processing of experiences represented up to a 43% decrease in visits to the general practitioner compared to the control group, where negative experiences were not processed and a 50% decline of number of visits to the general practitioner for various diseases [9]. The same author reports successful results with using therapeutic diaries and expressive writing in the treatment of trauma as well [9], other authors see results in the wider clinical practice such as in treatment of asthma and rheumatoid arthritis [13], treatment of pain [14], oncology [15] and cardiovascular diseases [16], but also for reducing anxiety and stress in connection with pregnancy [17].
CONCLUSION
As a final conclusion of this article, thanks to this knowledge and our own experiences we would also like to highlight that art has its therapeutic educational potential and offers even more when it mediates contact with one's own spiritual sources of love and hope that transcend the individual, thus contributing to a better understanding of one's own life mission and meaning of one's life.
1. Horňáková, Marta. Liečebná pedagogika. [Therapeutic Pedagogy - in Slovak] 1st ed. Bratislava: Department of Therapeutic Pedagogy, Faculty of Education of the Comenius University in Bratislava. 1999. 190 p. ISBN 80-8046-126-0
2. Majzlanová Katarína. Základy biblioterapie pre knihovníkov. [Basics of Bibliotherapy for Librarians - in Slovak] Banská Bystrica: Banskobystrický samosprávny kraj, Krajská knižnica Ľudovíta Štúra. [Banskobystrický self-governing region, Regional library of Ľudovít Štúr] 2017. 56 s. ISBN 978-80-85136-58-6 Available at: http://new.kskls.sk/domain/b5/files/edicia/zaklady_ biblioterapie_pre_knihovnikov_2017.pdf
3. Kotrbová Kvetoslava. Svojpomocné knihy v biblioterapii. [Self-help books in bibliotherapy - in Slovak] pp. 95-110. In Studia Scientifica Facultatis Paedagogicae №. 5/2022, Ružomberok: Catholic University, 2022. 179 s. ISSN 1336-2232 [online]. Available at: http://studiascientifica.ku.sk/wp-content/ uploads/2023/01/07_kotrbova_svojpomocne_knihy.pdf
4. Depression in adults: treatment and management. NICE guideline from June 29, 2022. [online] London: National Institute for Health and Care Excellence, 113 p. ISBN 978-1-4731-4622-8. Available at: https://www.nice.org.uk/ guidance/ng222 [cit. 2023-03-31]
5. Pardeck John T., Pardeck Jean A. Children in Foster Care: A Guide to Bibliotherapy. 1st ed. Westport: Greenwood Press, USA 1998. 103 s. ISBN: 031330775X
6. Bettelheim Bruno. Za tajemstvím pohádek - proč a jak je číst v dnešní době. 1975, 1976. [Behind the Secrets of Fairy Tales - why and how to read them Medicina i Iskusstvo: Tom 1, № 3·2023 ISSN 2949-2165 Medicine and Art: Volume 1, № 3·2023 19 nowadays] (From English to Czech translated by Lucie Lucká, 2000, 2017). 2nd update ed. Praha: Portál, 2017. 392 s. ISBN 978-80-262-1172-3
7. Kotrbová Kvetoslava, Sturz Attila, Solárová, Zlatica. Terapeutický potenciál Dostojevského poviedky Sen smiešneho človeka. [The therapeutic potential of the Dostojevsky´s short-story The Dream of Ridiculous Man - in Slovak] 2022, pp. 343-365. In Philologia. Journal of Institute of Philological studies of the Faculty of Education Comenius University in Bratislava, 32 (2), 2022, 392 p. ISSN 1339-2026 Available at: https://www.fedu.uniba.sk/fileadmin/ pdf/ Sucasti/Ustavy/Ustav_filologickych_studii/Philologia/Philologia_2022_2/PHILOLOGIA_2_2022_TLAC-25_343-365.pdf
8. Rainwater Janette. Vezměte život do vlastních rukou. 1979, 1989. [Take Life into Your Hands] (From English to Czech translated by Alena Hnídková, 1993) 1 ed. Praha: Grada, 1993.232 s. ISBN 80-7169-026-0
9. Pennebaker James W. Writing to Heal. A Guided Journal for Recovering of Trauma and Emotional Upheaval. 2nd ed. Oakland: New Harbringer Publications, 2013, 172 p. ISBN 978- 0-578-12942-6
10. Kotrbová Kvetoslava, Majzlanová Katarína. Terapeutický denník v biblioterapii. [Therapeutic Diary in Bibliotherapy -in Slovak] pp. 28-51. In Problems of Education in the Fourth Industrial Revolution Era. Collection of Scientific Articles. European Scientific e-Journal, 02-2021 (008). Hlučín-Bobrovníky: Tuculart Edition. ISBN 978-80-908088-1-2. Available at: http://tuculart.eu/ftpgetfile.php?id=172
11. Kotrbová Kvetoslava. Terapeutické listy v biblioterapii. [Therapeutic Letters in Bibliotherapy - in Slovak] 2022, pp. 68-82. In Problems of Education and Teaching in Era of Digital society. Collection of Scientific Articles. European Scientific e-Journal, 1-16. Ostrava: Tuculart Edition. ISBN 978-80-908353-7-3 Available at: http://tuculart.eu/ftpgetfile.php?id=273
12. Majzlanová Katarína, Kotrbová Kvetoslava. Význam príbehu v biblioterapii [Meaning of the story in bibliotherapy - in Slovak] pp. 149-172 In Bukor J., Szimon Sz. at all: Collection of scientific articles from the XI. International scientific conference of the J. Selye University 2019, Section Language-Culture-Relationships. J. Selye University Komárno Slovakia, 2019. 244 p. ISBN 978-80-8122-331-0. Available at: http://uk.ujs.sk/dl/3310 /MAJZLANOVA.pdf
13. Indroop D. (n. d.). Writing in your Journal/Diary. Available at: https://slideplayer.com/slide/13161597/ Medicina i Iskusstvo: Tom 1, № 3·2023 ISSN 2949-2165 Medicine and Art: Volume 1, № 3·2023 20
14. Thiele C., Laireiter A.R., Baumann U. Diaries in Clinical Psychology and Psychotherapy: A Selective Review. In Clinical Psychology and Psychotherapy 2020; 9, 1-37. Available at: https://onlinelibrary.wiley. com/ doi/ abs/10. 1002/ cpp.302
15. Moor C., Strener J., Hall M., Warneke C., Gilani Z., Amato R., Cohen L. A pilot study of the effects of expressive writing in a phase II trial of vaccine therapy for metastatic renal cell carcinoma. In Health Psychology Journal 2020 No. 21: 616-6019. Available at: https://pubmed.ncbi.nlm.nih.gov /12433015/
16. Manzoni G. M., Castelnuovo G., Molinari E. The Written-heart Study (expressive writing for heart healing): Rationale and Design of Randomized and Controlled Clinical Trial of Expressive Writing in Coronary Patients referred to Residential Cardiac Rehabilitation. In Health and Quality of Life Outcomes Journal. 2011, Jul 8, 9:51. Available at: https://pubmed.ncbi.nlm. nih.gov/21740564/
17. Quian J., Zhou X., San X., Wu M., Sun S., Yu X. Effects of expressive writing intervention for women's PTSD, depression, anxiety, and stress related to pregnancy: A meta-analysis of randomized controlled trials. In Psychiatry Research. 2020, Jun, 288: 112933 Available at: https://pubmed.ncbi.nlm.nih. gov/32315889/
