“Another Way to Talk About Feeling Bad”. Creative Interactive Bibliotherapy – A Complement to Treatment for Women with Mental Illness After Childbirth

ABSTRACT The purpose of this study is to investigate whether and in what respects creative interactive bibliotherapy can affect the mental and social well-being of women with postpartum mental illness. Four women with mental illness after childbirth read and discussed fiction in a reading circle for ten weeks, under the guidance of a licensed psychologist. The participants were observed during the reading circle and interviewed individually when the reading circle had ended. ). The result of the study shows that the women's social, mental, and intellectual well-being was positively affected. The participants felt less alone. Their thoughts and emotions were stimulated. They were strengthened in their identity, prioritized their own needs and became more active in their everyday lives. Given the results, creative interactive bibliotherapy seems to be a form of therapy that merits further research regarding the group of women with postpartum mental illness.


Introduction and purpose
Mental illness after childbirth is a prevalent and serious social problem in today's society. In Sweden it affects at least 15% of new mothers (National Board of Health and Welfare, 18 April 2017). In global terms there is reason to believe that the figure is much higher, because factors such as poverty and immigration are considered to increase the risk of being affected (Kendall-Tacket, 2005. One of the most common and best-known forms of perinatal mental illness is postpartum depression (PPD), but mental illness after childbirth spans a wide range of conditions and disorders of varying severity, from mild anxiety and depression to what is commonly referred to as psychiatric disorder. In addition to postpartum depression, these conditions include bipolar disorder, anxiety disorders, personality disorders, eating disorders, and psychosis (Sylvén, 2017).
In addition to the suffering that postpartum mental illness causes the women who experience it, there are a great many negative consequences for the people closest to the women, especially the newborn baby. Research shows that postpartum depression can negatively affect the mother-child relationship and have devastating effects on the mother, the child, and the whole family (Clark Amankwaa, 2003;Sword et al., 2008). From both an individual and a societal perspective, it is therefore important that women with mental illness after childbirth are identified by health care and offered adequate treatment.
The most common recommended treatments for postpartum mental illness in Sweden today are medication and psychotherapy (1177Vårdguiden, 2020. These methods are also the ones on which most research has been done regarding the target group. Medication is recommended above all for mothers with a severe depression, and is considered to have a particularly good effect on symptoms such as sleeping difficulties, appetite disorders, fatigue, decreased sexual desire, restlessness, and concentration difficulties (Kendall-Tacket, 2005. According to several studies, however, psychotherapy, especially cognitive behavioural therapy, and interpersonal psychotherapy, has been shown to be just as effective as drugs in treating depression (Claridge, 2014;Rupke et al., 2006).
Many women are also sceptical about taking medicine when they are affected by mental illness after childbirth. Many worry that the drugs will have side effects on breastfeeding children. Others see it as stigmatizing to take medicine. Many of these women prefer different forms of alternative therapies, either instead of or as a supplement to drugs. They feel that they have more control over this type of treatment, which has been held up as yet another reason for preferring it (Zauderer & Davis, 2012).
Alternative therapies are sometimes viewed with distrust by medical science. One reason is that the methods have generally not been researched to the same extent as traditional treatment methods such as medication and psychotherapy. Moreover, existing studies on alternative therapies have not followed the same rigorous standards as research into antidepressants, to take one example. In recent decades, however, there has been a change within the research field. In her book Depression in New Mothers: Causes, Consequences and Treatment Alternatives (2005/2017), Kathleen A. Kendall-Tacket, who is an authority in research on women's perinatal health, has considered a large number of alternative therapies that have recently been the subject of more extensive research. Some of these, such as light therapy, treatment with omega-3 fatty acid or with St. John's wort, have been shown to be effective in the treatment of PPD.
However, research has shown very little in interest in what alternative treatments such as art therapiespicture therapy, music therapy, and bibliotherapy for instancecan entail in the form of improved health or well-being for women with mental illness after childbirth. Kendall-Tacket (2005 briefly describes some studies showing that expressive writing has had a good effect on new mothers who have experienced posttraumatic stress and PPD. In an article, Cheryl Zauderer and Wendy Davis highlight bibliotherapy as a means of reducing stress and depression in new mothers (2012). However, in their short description of this therapy they do not include any studies of bibliotherapy for women with postpartum mental illness. Nor have I found any such studies, despite having searched relevant databases. 1 This is remarkable, especially since bibliotherapy has traditionally been used, and with good results, for the very kind of ill health that women often experience after childbirth, such as depression, anxiety, and post-traumatic stress, but in target groups other than women with postpartum mental illness (Cuijpers, 1997;Glavin & Montgomery, 2017).
The present study aims to investigate whether, and if so in what respects, bibliotherapy can affect the mental and social well-being of women with postpartum mental illness, and against the background of previous research it can be regarded as the first of its kind. The ambition of the study is to contribute in-depth knowledge of whether bibliotherapy could be an appropriate complement to other treatment for women with postpartum mental illness and whether further, more comprehensive studies of bibliotherapy should be conducted with the target group in question.

Bibliotherapy
Bibliotherapy involves the use of literature to promote health (McCarty Hynes & Hynes-Berry, 1986). In general, two different forms of bibliotherapy can be distinguished: self-help bibliotherapy and creative bibliotherapy. Self-help bibliotherapy, as the term suggests, uses self-help literature, and is often practised individually. The patient is recommended selected books by a doctor or therapist and then reads them largely on her own (Brewster, 2011). Creative bibliotherapy mainly uses fiction: novels, short stories, and poetry. Creative bibliotherapy is based on theories that literature can have a therapeutic effect because it is a safe place where the reader can experiment with different approaches to the literary world. The reader can enter into it and into the lives of the characters that populate it, exploring what it would feel like to be someone else, while still being able at any time to distance herself from it (McNicols, 2018). Unlike self-help bibliotherapy, creative bibliotherapy is often practised in groups. The literature is read and discussed under the guidance of a bibliotherapist or a group leader with some other form of training (Brewster, 2011). This form of discussion under the guidance of a leader is also commonly referred to as interactive bibliotherapy (McCarty Hynes & Hynes-Berry, 1986. Qualitative research has shown that creative interactive bibliotherapy can have a positive effect on social well-being, for instance by reducing social isolation, improving communication skills, and enhancing self-confidence (Pettersson, 2018;Tukhareli, 2018). Increased social well-being is very important for women with postpartum mental illness, a group that tends to be very isolated from the outside world. This can be explained by the decline in well-being itself, but also by the fact that postpartum mental illness is associated with a particularly strong taboo: feeling bad after giving birth, when as a mother one is expected to be happy (Nicholson, 2003;Mauthner, 2003). Therefore, because of its positive impact on social well-being, creative interactive bibliotherapy, in the form of a bibliotherapeutic reading circle, has been used in the design of this study.

The organization of the reading circle
The bibliotherapeutic reading circle that is the subject of this study was carried out in Gothenburg, the second largest city in Sweden with about 600,000 inhabitants. The reading circle was arranged in collaboration with Folkuniversitetet, which is one of Sweden's largest study associations, organizing study circles in many subjects and for different target groups. Participation in the reading circle was free of charge.
The reading circle met ten times, once a week over a ten-week period from January to April 2019. Each session lasted an hour and a half. The circle was led by a licensed psychologist with experience of working with art and literature. I participated as a researcher with personal experience of postpartum mental illness, and this was declared at the first meeting of the group. Knowing about this, and about the group leader's profession, was judged to be important for the participants' confidence in us and for the legitimacy of the reading circle. If any of them were to show signs of a worsening condition during the period, that person would be assured that the group leader had adequate knowledge to respond to it and, if necessary, help the person in question to get in touch with health care.
Each meeting followed the same arrangement. It began with a warm-up exercise which consisted of a conversation about a reproduction of a work of art that the group leader had chosen and copied for distribution at each meeting. The exercise was intended as an unpretentious way to stimulate a free conversation about the artwork and the thoughts and associations that it aroused. Then the actual bibliotherapy began. The participants had been sent, in advance and at no cost, a number of short stories, chapters from novels, and poems. They read a short story, a chapter from a novel, or a few poems at home before each meeting of the circle. 2 At each meeting the first pages of the day's text were also read aloud in the group. The idea behind this was that it would create calm and concentration in the group and remind the participants what the text was about. At the first meetings, the group leader did the reading, but when the circle had been running for a few weeks, the participants were also invited to read aloud. All participants read aloud on at least one occasion.
After this reading there were conversations about literature, which can be regarded as the very core of interactive bibliotherapy. The participants were given the opportunity to express their opinions about the text and what reading it had meant for them and for their health and well-being. In my capacity as researcher, I had prepared, together with the group leader, a number of questions that could be used if necessary. Some of these questions centred on the participants' life situation and possible similarities between them and the characters in the texts, while others focused more on the experience of the reading and the participants' fantasies and associations concerning the texts.

Participants
Six women signed up for the reading circle, but two of them never turned up, which meant that in the end there were four women who took part and carried on until the end. As a result, this is a small study, which of course affects the general conclusions that can be drawn from it. Given that previous research on self-help groups for women with postpartum mental illness has shown that this group is very difficult to recruit (Ugarriza, 2004), the number of participants may nevertheless be perceived as satisfactory. The fact that attendance rates were high also gives an indication of the importance of the reading circle for the women. 3 All the women who participated lived in Gothenburg or in the region to which the city belongs, Västra Götaland. Before going on parental leave or sick leave they had worked in the following professions: doctor, public-authority librarian, teacher, and construction manager. Having professions of this kind, the women can be regarded as a relatively homogeneous group, belonging to the middle class. One of them had already returned to work full-time, one did so while the reading circle was in progress, and two were on parental leave and/or sick leave.
At the first meeting of the circle, the women were given both oral and written information about the study and consented to participate in it. The written information stated that the material for the study would be collected through interviews and observations and that all material would be anonymized when transcribed so that it could not be traced back to the participants by anyone but the researcher. Consequently, the names used in the analysis are fictitious. It was also emphasized that participants could at any time withdraw from the study without having to state a reason, and that under the EU General Data Protection Regulation they had the right to access the data about themselves free of charge. They could also request that data about them be deleted and that the use of their personal data be restricted. All participants gave their written consent to participate in the study.

Method
The material for the research study consists of participant observations of all the meetings of the circle, the group leader's notes on each session, and the individual interviews with the participants and the group leader after the reading circle was concluded. The combination of these different qualitative methods resulted in material triangulation (Rothbauer, 2007). The purpose of generating material reflecting how the participants, the researcher, and the group leader viewed the reading circle was to give as nuanced a picture as possible of the circle activity and its impact on the participants' experience of health and well-being.
The participant observations can be described as structured observations where the observer was known to the participants. Based on an observation design inspired by Patty Sotirin's four points for classroom observations, especially the points "People" and "Talk", material was collected about the conversation and interaction in the group (Sotirin, 1999). The group leader's notes can be described as a kind of unstructured observation, which also focused on the interaction in the group. The observations were written down immediately after each meeting of the circle, not while it was in progress. It might have interfered with the interaction in the group if the leader or the researcher had taken notes while it was going on.
The individual interviews were conducted after the last circle. They were semi-structured and were based on an interview guide with questions that focused on the participants' experience of the reading circle and its impact on their health and well-being, as well as on the literature that was read by the circle. Each participant was interviewed once. The interviews took between 30 and 50 minutes. The leader of the circle was also interviewed. The interview guide that was used with her concentrated on how she felt that the group activities had worked for the participants as well as issues related to leadership.
The interviews with the participants were analysed using thematic analysis as described and applied by Braun and Clarke (2006). The interviews were transcribed by me, which meant that I became more familiar with the material already at this stage. Personally transcribing the material one is going to work with is usually considered an advantage in thematic analysis, since the analysis phase begins during the transcription (Braun & Clarke, 2006). Once all the interviews had been transcribed, I listened and read through them several times. Parallel to this, work began on encoding the data and compiling a list of the different codes that were distinguished in the interviews. The codes were then sorted into potential themes. These themes were then tested against the interview material in order to investigate whether they were sufficiently substantiated by the coded data or if they needed to be merged or broken down into several subthemes. This process went on until the analysis was completed. When the themes were finally established, I reread the entire interview material to check that the themes reflected the meaning of the interview material as a whole.

Results
All the women (referred to below as Therese, Tilda, Nina, and Frida) found it a positive experience to participate in the reading circle and felt that their well-being had increased during the period. The thematic analysis of the interviews revealed five themes describing the ways in which participation in the reading circle contributed to increased social, mental, and even intellectual well-being. These themes are the social, intellectual, identity-enhancing, self-rewarding, and activity-promoting functions of the reading circle. The social function can in turn be divided into the subthemes of community and communication.

Community
The theme of community includes the opportunity to meet others who are in the same situation as oneself. Frida said she felt less alone thanks to this opportunity. She and two of the other participants stressed that it was important to meet other people who share the experience of postpartum mental illness through the reading circle. This shared experience meant that, as Tilda put it, they have "a basic understanding of each other". They did not need to explain what it means to have mental illness, which they felt they needed to do for people who do not have that experience and who may also be unfamiliar with the phenomenon of mental illness after childbirth.
The shared life situation and mutual understanding, combined with the fact that it was the same participants in the group each time, gave a sense of security. Frida believed that this gave her the courage to be rather more open. Both she and Nina thought it was good that I, as a researcher and participant observer, was frank about the fact that I myself had experience of postpartum mental illness. This generated trust among the participants and strengthened the sense of security and community in the group. Frida also believed that the literature that was read and discussed contributed to the sense of community because it contained depictions of ill health or vulnerability which showed participants that they were not alone in feeling the way they felt.
The perception that participants became more confident during the reading circle is reinforced by the observations made. The participants seemed more relaxed and comfortable later in the course of the circle, taking an increasingly active part in the discussions. The circle leader also noted that they grasped the comic element in the text they had to read for the eighth meeting, but not the comic element in the text for the third meeting; this was interpreted as an expression that they felt better at the end than at the beginning (Circle leader's observation, 22 April 2019).

Communication
Communication in this context means the actual possibility of discussing matters relating to health or personal life on the one hand and literature on the other. The participants stress that an important aspect of the reading circle was the opportunity for conversation itself and, above all, the open climate of conversation. The opportunity to talk freely about mental illness in a non-judgemental context is something that women said they have appreciated about the reading circle. Therese believed that this was particularly important because she did not know anyone else who had experienced mental illness after childbirth with whom she could share these experiences. Other aspects of life that women could bring up and where they said that they received support and understanding from the group concerned difficult relationships in the workplace and life with a baby as a whole. Therese emphasized that being able to formulate herself in the group about her anxiety and feeling the support of the other participants was of "enormous help". It contributed to improved mental well-being.
Frida would have liked to have a greater focus in the conversations on her own health. The other participants, however, appreciated the opportunity to control for themselves the extent to which they talked about their health and the extent to which they focused on literature. Tilda described the conversation in the group as "another way to talk about feeling bad that wasn't so personal" and spoke about this in very positive terms. She believed that the conversation about literature was an opportunity to relate the bad feelings to a societal and gender-equality perspective and thus to put the phenomenon of postpartum mental illness in a broader context.

Intellectual function
If the theme of communication focuses on the conversation itself and its importance for the participants' well-being, the theme of intellectual function is more about the effects of the conversation and, above all, those parts that were directly related to literature. All the participants thought that the conversation about literature triggered thoughts in them and that the literature helped them to express their feelings and thoughts freely. They talked about how the conversation deepened the individual reading experience and how they had arrived at a better understanding of the text when we talked about it in the group. Interestingly, this seemed to apply above all to the texts that they first found strange or difficult. They appeared in a different light and were perceived as more multifaceted thanks to the conversations. As Tilda expressed it, she "got a different angle on the text through the conversation". She also explicitly said that the conversation "was food for the intellect" and repeated that this aspect of the reading circle was very important to her. She contrasted the reading circle with her job, which she found "rather strict", and with her everyday life as a mother of a baby, more focused on practical chores, and she believed that the reading circle satisfied the need for intellectual stimulation that she could not have satisfied in other contexts.

Identity-enhancing function
An additional function of the reading circle that crystallized as a theme in the analysis is that it served to strengthen the women's identity. All the participants already had relatively long experience of reading and thus identified themselves as readers. The reading circle confirmed this identity, which was particularly evident in a couple of cases. Tilda, who emphasized the importance of the reading circle for the intellect, also highlighted its identity-enhancing function when she said that the reading circle and the conversations about literature had "carried [her] back to a part of [herself] that had been dormant". She described herself as a person who loved to study and participate in discussion groups and who came to life in those contexts. Through the reading circle she was given an outlet for this aspect of herself in a life situation that otherwise did not allow much room for reading and discussion.
Therese gave a highly concrete example of how, above all, the reading of the Swedish poet Karin Boye's poem "I rörelse" ("On the Move") which was a part of the reading circle strengthened both her identity and her self-confidence. She told of how she felt that one of the poem's closing lines, which reads "Move on, move on! The new day is dawning", put into words the life situation she was in and gave her confirmation that the changes she was making in her life were good for her: "It gave some kind of strength and some confirmation that I'm moving on now. I'm now leaving what I've been doing and moving towards something new. It'll be good!"

Self-rewarding
The fourth theme I have called a self-rewarding feature. The concept of self-rewarding value is often used in occupational therapy, referring to activities that the person in question thinks are fun or enjoyable to perform (Persson et al., 2001). In this article I use the term self-rewarding in a similar way. The self-rewarding function of the reading circle is reflected, for example, in Tilda's description of it as "a breathing space". She added that, if she could, she would have continued to participate in a reading circle like this for the rest of her life, which strengthens its importance to her as an activity she engages in entirely for her own sake.
Nina also dwelled heavily on the self-rewarding function of the reading circle. She described her experiences in the words: "It's been like being able to enter a little literary bubble for an hour and a half" and she had "really appreciated going into that bubble". Later in the interview, she returned to the self-rewarding function of the reading circle and said that she did not think she would have indulged in reading the texts included in it if the reading circle had not existed and met at set times. This makes it clear that a structured context like the reading circle is often required for the self-rewarding function of reading to be realized.

Activity-promoting function
The fifth and final theme can be summed up in the term "activity-promoting". Participation in the reading circle had the result that the women performed more activities outside the circle.
One such activity was reading. Nina, Therese, and Frida stated that their interest in reading had been stimulated by participation in the circle and that the literature and the authors they read in the circle influenced what they read in their spare time. Participation in the reading circle thus broadened their literary horizons. One of the women became particularly interested in the Swedish author Bodil Malmsten, an extract of whose autobiographical novel The Price of Water in Finistère was read in the group. This interest led her to read more works by Malmsten. At the second last session she brought along one of the books she had acquired, showed it to the group and told the group about it (the researcher's observation note, 29 March 2019). This action can also be seen as an expression of increased self-confidence and a greater ability to assert herself in the group discussion. Nina told of how she took a work of fiction with her when she was travelling for work. Although she had not had any opportunity to read the book during the trip, she said that she thought it was good to know that the book was in her luggage and that she could have read it if the circumstances on the trip had been different.
Another type of activity promoted by participation in the circle was the ability of women to move outside the home. Frida said that when she was at her worst, she found it very difficult to leave home and just wanted to isolate herself in her flat. But through participation in the reading circle and in another group, she felt less alone, which made it easier for her to take more initiatives to socialize outside the home. Therese likewise found it hard to leave home when she was feeling at her worst. When the reading circle began, she had started to feel a little better, but she still felt it was a big step to go to the meetings of the circle. In her case, it meant that she needed to drive for about an hour, in other words, it took a great deal of effort both physically and mentally. The fact that she was able to do so confirmed that she had overcome a fear and had matured.
Therese went on to say that she used to have a cup of coffee in a nearby café before each meeting of the circle and take a walk afterwards, which can also be seen as an expression of her increased ability to move around outside the home and thus an example of the circle's activity-promoting function. In her case the café visits and the walks almost took on the character of a ritual, which framed the circle meetings and gave them a special position in her everyday life.
Another activity related to participation in the reading circle was the gardening that Tilda indulged in. She said that, after reading the extract from "The Price of Water in Finistère", which is about the storyteller's garden, she felt the urge to work in her own garden. She also thought about the author and her novel as she was gardening. "And it was a happy thought", she added, reinforcing the perception of the positive impact of the reading circle on her mental well-being. The fact that she thinks about literature while performing another activity suggests that it forms an integral part of her everyday life and thus connects the reading circle with it and creates a meaningful whole. Similar examples of how the reading done for bibliotherapeutic purposes has become an integral part of the participant's everyday life can be found in previous research on creative interactive bibliotherapy (Pettersson, 2018).

Discussion and summary
The aim of the study was to investigate whether, and if so in what respects, creative interactive bibliotherapy can affect the mental and social well-being of women with postpartum mental illness. The results show that both social and mental well-being were positively affected in a number of ways, as was intellectual well-being. In concrete terms, this increased well-being is reflected in the fact that the participants have felt less alone, have had an opportunity to discuss their mental illness with people in the same life situation and in a safe environment, have experienced stimulations of thoughts and emotions and have been strengthened in their identity. The increased well-being can also be related to the fact that they have prioritized their own needs by participating in an activity that they have found pleasure in, and that they have become more active in their everyday lives in various ways. Creative interactive bibliotherapy thus appears to be a form of therapy that deserves further research in relation to the group of women with postpartum mental illness.
Finally, I would like to consider two aspects that may have influenced the positive outcome of the study and point to its potential for further development.
One aspect that seems to have been important for the positive outcome of the study is that the reading circle was aimed solely at women with postpartum mental illness. This shared experience meant that the women did not feel any need to explain to each other what it means to have mental illness after childbirth, which gave a feeling of relief and security. In addition, the knowledge that the others had also experienced mental illness after childbirth confirmed that they were not alone in their situation, and it gave them an opportunity to talk about the mental problems they experienced without feeling that the other participants were judgemental towards them. Since postpartum mental illness is still very much a taboo subject in society as a whole, as a couple of the participants also pointed out, these opportunities provided by the reading circle seem particularly important. Future interventions with bibliotherapy aimed at women with postpartum mental illness should therefore be constructed so that postpartum mental illness is a crucial criterion for participation.
Another aspect that may have had an impact on the outcome of the study is that, at the time when the reading circle started, the women already had an interest in reading and were relatively accustomed readers. They also had occupations that require long education and experience of studying, which may also have helped them to benefit from the reading circle more than a person with lower education and less interest in reading would have done. At the same time, previous research has shown that interactive bibliotherapy has also had a good impact on people with little experience of reading or with less education (Shechtman, 2009;Tukhareli, 2018). Whether creative interactive bibliotherapy also has a favourable impact on women with postpartum mental illness who have a lower level of education and less reading experience remains to be investigated. Notes 1. Searches have been performed in the databases PubMed and JSTOR, combining the search terms "bibliotherapy" and "postpartum depression" and "bibliotherapy" and "mental illness after childbirth". In PubMed, only one hit was obtained, in this case with the combination "bibliotherapy" and "postpartum depression", and that hit was a study examining the importance of reading for language development in young children who had parents with postpartum depression, and thus did not concern how reading can be used to affect the parents' health or well-being; see Paulson et al. (2009). JSTOR yielded no hit for any of the search combinations.
2. For a specification of the literature, see Appendix 1. 3. Two of the participants attended nine of the ten meetings, one attended seven and one attended five. The high attendance also means that the material on which the research study is basedobservations and interviewsis a fair representation of the participants' experiences of the reading circle.

Disclosure statement
No potential conflict of interest was reported by the author(s).