Promoting Bibliotherapy As a Tool for Therapeutic

Home , Bibliotherapy

PROMOTING BIBLIOTHERAPY AS A TOOL FOR THERAPEUTIC

ENGAGEMENT WITH YOUTH

Matthew Skinner

A Project Presented to

The Faculty of Humboldt State University

In Partial Fulfillment of the Requirements for the Degree

Master of Social Work

Yvonne Doble, MSW, Advisor

Jamie Jensen, MSW, Committee Member

Chandra Gonsales, MS, Community Partner

Geneva Shaw, MSW, Graduate Coordinator

July 2016

Abstract

PROMOTING BIBLIOTHERAPY AS A TOOL FOR THERAPEUTIC ENGAGEMENT WITH YOUTH

Matthew Skinner

According to Merriam-Webster (2015), bibliotherapy is “the use of reading materials for help in solving personal problems or for psychiatric therapy.” The goal of this project was the promotion of bibliotherapy for therapeutic engagement with youth in a rural mental health setting. According to Hiatt (2006), the ADKAR Model of Change consists of awareness, desire, knowledge, ability, and reinforcement. Using the ADKAR Model of

Change as a framework for development and supporting organizational change, a bibliotherapy implementation guide was created for clinicians at a rural, Northern

California mental health agency. The purpose of this guide was to introduce bibliotherapy to clinicians who are unfamiliar with it, and to promote it as a potential practice for working with youth in a rural area. A literature review on bibliotherapy was a part of this project.

Acknowledgements

Thank you to Chandra Gonsales, MS for initially providing the inspiration for this project. Thank you to Yvonne Doble, MSW for your patience, support and significantly helpful input. A very special thank you is owed to Jamie Jensen, MSW, who has been an invaluable support and helper in this project.

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Table of Contents

Abstract ...... ii

Acknowledgements ...... iii

List of Appendices ...... vi

Introduction ...... 1

Background ...... 2

Project purpose ...... 3

Project context ...... 3

Size/severity/cost ...... 6

Literature Review...... 7

Definition and goals of bibliotherapy ...... 7

Problems/gaps ...... 7

History of bibliotherapy ...... 8

Constructive-Developmental Theory as a framework for bibliotherapy ...... 10

Process of bibliotherapy ...... 12

Selection of appropriate materials ...... 12

Benefits of bibliotherapy ...... 14

Parents as providers of bibliotherapy ...... 15

Efficacy of bibliotherapy with specific diagnoses ...... 15

Methodology ...... 18

Lewin’s Change Theory ...... 18

ADKAR model of change ...... 19 iv

Awareness ...... 20

Desire ...... 21

Knowledge ...... 22

Ability ...... 22

Reinforcement ...... 23

Results ...... 25

Project phase one: Presentation of the implementation guide ...... 26

Project phase two: Development of resource bookshelf ...... 27

Conclusions ...... 28

Sustainability ...... 29

Lessons learned ...... 30

Future steps ...... 31

References ...... 33

Bullying ...... 39

List of Appendices

Appendix A: Example Books for Use in Bibliotherapy ...... 39

Appendix B: Bibliotherapy Implementation Guide Table of Contents ...... 43

Appendix C: Web-Based Bibliotherapy Resources ...... 44

Introduction

According to Merriam-Webster (2015), bibliotherapy is “the use of reading materials for help in solving personal problems or for psychiatric therapy.” Bibliotherapy is a therapeutic intervention in which clients engage with a book or other reading material independently from their home, while participating in regular telephone check-ins with a therapist. This project introduces this practice as a way to fill the gaps in service delivery to rural clients ages 24 and under within the mental health system in Mendocino County.

These gaps, including Health Professional Shortage Areas (HPSAs), will be discussed later in this paper. A bibliotherapy implementation guide was created as a resource to the partner agency and clinicians. A literature review was conducted to inform the development of the guide.

In discussing this project with fellow staff members, it became apparent that many were initially unaware of what bibliotherapy is. One therapist heard “bibliotherapy” and thought it was associated with teaching the Holy Bible. It will be important for the agency to train new clinicians (and existing ones) on the potential benefits of this practice, using the implementation guide that was created. The importance of training therapists in this therapeutic technique corresponds with the ADKAR Model of Change, which will be discussed in this paper (Hiatt, 2006).

Background

Redwood Community Services (RCS) provides mental health services to clients

who live in rural areas. The service region of RC3/RCS is the entire county of

Mendocino. According to the US Department of Health and Human Services (2011),

children who live in rural areas are more likely to live in financially poor homes and face

greater challenges in accessing needed services due to geographical challenges.

As of 2010, of the 2,052 non-metropolitan counties in the United States, 521 of

these counties were designated as HPSAs for mental health services (US Department of

Health and Human Services, 2011). According to Thomas, Ellis, Konrad, Holzer and

Morrissey (2009), documenting the supply of mental health professionals within communities can highlight the distribution of them between sectors. Examples are mental health professionals working in private practice, which can leave public services in shortage, and working in residential institutions, leaving them unavailable to work in outpatient settings (Thomas, et al., 2009).

According to Pullmann, VanHooser, Hoffman, and Heflinger (2009), rural mental health utilization rates are lower than urban rates, for both outpatient and inpatient mental health services. Children and adolescents are generally reliant upon adults to access services. For children with strong family supports, this is helpful to ensuring consistency in treatment. For children and adolescents who come from families that have limited resources, generational experience in mental health or struggles with substance abuse, this dependence often causes barriers to access (Pullmann et al., 2009). With support and

guidance, family and school systems can offer potential support to children and

adolescents in accessing mental health services.

Project purpose

The promotion of bibliotherapy as a tool for therapeutic engagement with youth in

a rural mental health setting was the purpose of this project. It is hoped that bibliotherapy

will allow clients to utilize age-appropriate reading materials, along with regular

telephone check-ins with a therapist, so that healing can occur regardless of where they live. According to Hiatt (2006), the ADKAR Model of Change consists of awareness, desire, knowledge, ability, and reinforcement. Using the ADKAR Model of Change as a

framework for development and supporting organizational change, a bibliotherapy

implementation guide was created for clinicians at a rural, mental health agency in

Northern California. A bibliotherapy implementation guide was created. The purpose of

this guide was to introduce bibliotherapy to therapists who are unfamiliar with it. The

guide also aims to promote this as a potential technique while working with youth in a

rural setting.

Project context

According to Smalley, Yancey, Warren, Naufel, Ryan and Pugh (2010), some of

the challenges that mental health service consumers in rural areas face are a lack of

transportation to services, a lack of knowledge about when services are necessary, where

to receive services, and an inability to pay. Clients often lack adequate transportation to

4 services. According to Gulliver, Griffiths, and Christensen (2010), a lack of adequate transportation is a common barrier to accessing mental health services in rural areas.

According to Boydell, Pong, Volpe, Tilleczek, Wilson, and Lemieux (2007), residents of rural communities generally face greater challenges in accessing mental health services.

Geographic and economic factors such as travel expenses increase the costs of accessing and providing care. This author will use Covelo as an example of one rural community within Mendocino County. The town of Covelo is not of any more significance than any other rural area within the county in this project. All rural areas have the potential to be served while utilizing bibliotherapy.

Covelo is one of the most rural towns in the county, with a high concentration of

Native Americans. According to Anderson (2010), Covelo has approximately 4,000 residents, half of whom are Native Americans. Many of them have a distrust of governmental figures. Covelo is currently experiencing low academic achievement, high unemployment rates, crime, and drug and alcohol abuse (Anderson, 2010). According to

Cohen (2015), during the years 2010-2012, Mendocino County had exceeded the state of

California’s levels of drug abuse. Covelo’s rural setting combined with the area’s stressors highlight the potential of bibliotherapy being used with people who experience transportation challenges to areas of the county where mental health services are provided.

This author is employed as a mental health crisis worker for the Redwood

Community Crisis Center (RC3), a program of RCS in Mendocino County. RCS is a non-

profit, non-sectarian agency that is contracted with the County of Mendocino to provide mental health services to the 24 and under age range. RCS was incorporated in October,

1995 and began as a foster family agency. RCS has since expanded to become a multi- program agency serving the needs of the community. It is the largest provider of children’s mental health and foster care services in the counties of Lake, Mendocino and

Sonoma. RCS’ mission statement is “To improve the lives of children, youth and families by providing community support and quality therapeutic services” (RCS, 2015). The agency changed its name from “Redwood Children’s Services” to “Redwood Community

Services” on July 1, 2015 (Ukiah Daily Journal, 2015).

The promotion of bibliotherapy as a tool for therapeutic engagement with youth has the potential for helping clients gain insights into their mental health disorders and life stressors. It is hoped that this project will help clients by promoting health and well- being. Bibliotherapy will be an option for clients; never a requirement. RCS serves clients in different contexts (e.g. crisis services, foster care, individual therapy, family therapy, mental health housing, case management, individual rehabilitation, linkage to outpatient psychiatry). RC3 provides mental health services during the initial crisis, and for 60 days post-crisis. This author is mainly involved in crisis intervention services, although he does provide some case management and individual rehabilitation services.

There is no person this author is aware of who has done similar work within the local

community.

This project initially stemmed from the manager at RC3 expressing interest in implementing a new practice. The RC3 manager has expressed interest in implementing bibliotherapy, which should prove to be a positive support in this project. Bibliotherapy is not currently being utilized as an intervention technique at RC3. The rural context of

Mendocino County creates challenges for service delivery of mental health services.

According to Smalley, et al. (2010), mental health service consumers in rural areas often express that it is difficult for them to obtain services due to the location of their residences in relation to where services are provided. Within Mendocino County, RCS generally provides mental health services in Ukiah, Willits, and Fort Bragg.

Size/severity/cost

RCS is the sole provider of mental health crisis services in Mendocino County for the 24 and under age range. Crisis services are also provided on a follow-up basis. Clients can see crisis workers and therapists for 60 days past the point of the initial crisis. As a department that is often providing services to clients who have the highest potential for lethality due to risk of being a danger to themselves or others, it is important that effective services be employed. Bibliotherapy is not a practice that would place a large financial burden on the agency or clients. As a part of this project implementation and sustainability, this author will facilitate the donation of a bookshelf to the crisis center, along with reading materials that can be provided to clients in need.

Literature Review

The following is a literature review that will address multiple areas of the subject of bibliotherapy. It will begin with the definition and goals of bibliotherapy, and proceed to problems/gaps. Then, its history will be discussed, followed by the process of bibliotherapy, the selection of appropriate materials, its benefits, and its efficacy with specific diagnoses.

Definition and goals of bibliotherapy

According to Merriam-Webster (2015), bibliotherapy is “the use of reading materials for help in solving personal problems or for psychiatric therapy.” According to

Cook, Earles-Vollrath, and Ganz (2006), bibliotherapy has six potential goals: to provide information, insight into problems, alternative solutions to problems, begin a discussion of what the problem is, discuss new attitudes and values about the problem, and assist students in discovering that other people have experienced similar issues. Bibliotherapy allows children to relate to literary characters who are similar to themselves. This can allow children to learn how to solve their own problems by reading about how a character solved theirs (Cook, et al., 2006).

Problems/gaps

Bibliotherapy requires that children are able to read and understand the material.

According to Carlbring et al. (2011), bibliotherapy can be ineffective for people with

8 severe mental health issues, poor reading abilities, and a lack of motivation to follow a self-directed reading program. Bibliotherapy requires clients to be self-motivated to continue reading materials. Therapists must be familiar with the materials that they present to clients, as they engage in discussions with them.

According to Lewis, Amatya, Coffman and Ollendick (2015), bibliotherapy often requires that parents read the materials to their children. Young children are often unable to independently read the materials. With proper parental supervision, children are often able to more fully comprehend the materials that are being presented. When parents are unable to dedicate this amount of time and energy to their child’s bibliotherapy process, it can hinder the child’s progress (Lewis et al., 2015).

History of bibliotherapy

According to Jack and Ronan (2008), library epigraphs appeared in ancient

Greece as early as 300 BC. The earliest record of prescribed reading came in 1272 at the

Al-Mansur hospital in Cairo, Egypt. Libraries within psychiatric hospitals began to appear in the 1700s. In 1802, Dr. Benjamin Rush was one of the first physicians from the

United States to prescribe reading as part of patients’ treatment plans. In 1846, Dr. John

Minson Galt II wrote an article on the therapeutic use of books to treat his mentally ill patients. In 1904, the first professional librarian was hired in a psychiatric hospital. In

1916, Samuel Crothers coined the term “bibliotherapy.” In 1923, bibliotherapy was implemented in a Veterans Administration (VA) hospital. In 1936, the first writing on its

use for/with children appeared. The first dictionary definition of “bibliotherapy” appeared

in 1941. The American Library Association held a three-day workshop on bibliotherapy

that was attended by librarians, chaplains, educators, psychologists and therapists in

1964. Since 1970, there have been expansions in definition and use of bibliotherapy (Jack

and Ronan, 2008).

According to Myracle (1995), until the mid-1800s, the majority of children’s

books attempted to instruct children in religious and moral values. During the final half

of the eighteenth century, an increasing number of books were geared toward entertaining

youth. Examples of these works include Alice in Wonderland by Lewis Carroll, The

Wizard of Oz by L. Frank Baum, The Wind in the Willows by Kenneth Grahame, and

Little Women by Louisa May Alcott. During the early 1900s, there was a growing interest

in fiction novels for children and adolescents. Tom Swift, Nancy Drew, and The Hardy

Boys, all by Edward Stratemeyer, are some of the most well-known of this era. During this time, these materials still treated youth in a sentimental and moralistic manner. The mid-1950s brought a new era in books for children and adolescents. In 1951, The Catcher in the Rye, by J.D. Salinger was published. Soon thereafter, materials for youth began to address issues such as suicide, homosexuality, divorce, alcoholism, teenage pregnancy, abortion, and AIDS (Myracle, 1995).

Constructive-Developmental Theory as a framework for bibliotherapy

An overview of the Constructive-Developmental Theory will be discussed in this section, as it can be used as a framework for the use of bibliotherapy. The theoretical process, as it relates to bibliotherapy, will be discussed in this section.

McCauley, Drath, Palus, O’Connor and Baker (2006) found the following regarding the Constructive-Developmental Theory:

The term “constructive-developmental” was first suggested by Kegan (1980) to

refer to a stream of work in psychology that focuses on the development of

meaning and meaning-making processes across the lifespan. The theory is

“constructive” in the sense that it deals with a person's construals, constructions,

and interpretations of an experience, that is, the meaning a person makes of an

experience. It is “developmental” in the sense that it is concerned with how those

construals, constructions, and interpretations of an experience grow more

complex over time (McCauley et al., 2006).

The Constructive-Developmental Theory supports the use of bibliotherapy due to its focus on human behavior and the social environment. This relates to Kegan’s (1980) work in psychology that focuses on the development of meaning and meaning-making processes. It is “constructive” in the sense that it relates to a child’s interpretation of an experience. It is “developmental” in the sense that it deals with how a child’s construals,

11 constructions, and interpretations of an experience grow over time (McCauley et al.,

2006).

The Constructive-Developmental Theory is an appropriate framework to support the use of bibliotherapy. The theoretical process of bibliotherapy stems from psychotherapy’s principles of identification, catharsis, and insight. Identification occurs when the reader identifies with a character in a story and the situation they are facing.

Catharsis occurs when the reader experiences emotions that were repressed prior to becoming engaged in bibliotherapy. Insight occurs when the reader views their situation from a new perspective, and gains the motivation to make positive changes (Rozalski et al., 2010). This parallels the Constructive-Developmental Theory. The Constructive-

Developmental Theory asserts that a person’s ways of understanding themselves and their situations grow over time. A continuous process of development occurs in which meaning evolves through time, “both as a natural unfolding as well as in response to the limitations of existing ways of making meaning” (McCauley et al., 2006). As in the principles of identification, catharsis, and insight, the Constructive-Developmental

Theory asserts that each meaning system is more complex than the previous one, as it can include, differentiate among, and integrate multifarious experiences (McCauley et al.,

2006).

Process of bibliotherapy

According to Prater, Johnstun, Dyches and Johnstun (2006), bibliotherapy should

be followed in ten basic steps. First, develop rapport and trust with the child. Second,

identify other professionals who may be able to assist in the process. Third, solicit

support from the child’s guardian(s). Fourth, define what the issue(s) are that the child is

experiencing. Fifth, create goals and activities that properly address the issues(s). Sixth,

select reading materials that are appropriate for the child/adolescent to read. Seventh,

present the material to the student. Eighth, implement reading activities with the child.

Ninth, implement post-reading activities for the child. Tenth, evaluate the effectiveness of bibliotherapy on the student (Prater et al., 2006).

According to Heath et al. (2005), bibliotherapy should not be regarded as a type of treatment that is the sole intervention to promote change. Three basic rules should be followed. Bibliotherapy should be used alongside other therapeutic interventions, bibliotherapy progress should be monitored and documented by the therapist, and reading materials should be carefully selected so that children can understand the storyline, and be reading about characters facing similar situations.

Selection of appropriate materials

Moulton, Heath, Prater and Dyches (2011), provide an example of how the implementation of bibliotherapy with children can help to decrease instances of bullying in schools. Bullying is a common and problematic issue in modern-day schools. In this

study, researchers utilized 38 books with themes of bullying. Keeping these issues in

mind, professional helpers should be careful to appropriately choose appropriate reading

materials for the situation, and work toward encouraging appropriate solutions. The

appropriate application of reading materials can help children to understand and discuss

their feelings, while being able to increase the insight they have into their situations. To

change bullying behaviors, helping children to change their thoughts and perceptions

surrounding it are important. This is an area, according to this article, that aligns with

CBT. Encouraging dialogue in the classroom, decreasing isolation, building coping skills,

setting boundaries regarding behaviors, and offering children hope can prove to be

helpful (Moulton, et al., 2011).

There are endless issues that can be addressed through the use of bibliotherapy,

including: children of divorce, trauma experiences, eating disorders, grief/loss, substance

use or abuse and living with a mental health diagnosis. Therefore, it is important for

clinicians to conduct a thorough assessment of the child and familiarize themselves with

the material being presented. For example, when working with children who are being bullied, some considerations to take into account are the genders of the bully and the victim, the type of bullying, the bullying location, witnesses’ and adults’ reactions to the bullying, and the resolutions to these issues (Moulton, et al., 2011).

Benefits of bibliotherapy

According to Prater, Johnstun, Dyches and Johnstun (2006), bibliotherapy has five major benefits. First, bibliotherapy helps youth to be expressive about the issues they are facing. Second, it helps children and youth to critically think about their thoughts and actions in comparison to others. Third, bibliotherapy can help to provide youth with practical information to help in problem-solving activities. Fourth, it can reduce anxiety when youth realize that others have experienced similar circumstances. Fifth, bibliotherapy can create a new, fun way of trying to find solutions to their problems

(Prater et al., 2006).

According to Rozalski, Stewart and Miller (2010), bibliotherapy is divided into two areas of practice: developmental and therapeutic. Developmental bibliotherapy is often utilized by school teachers to assist children in adjusting to normal life transitions.

Therapeutic bibliotherapy is utilized by therapists in the mental health profession to address more specific issues that the client is facing (Rozalski, et al., 2010). The theoretical process of bibliotherapy stems from psychotherapy’s principles of identification, catharsis, and insight. Identification occurs when the reader identifies with a character or their situation. Catharsis occurs when the reader experiences emotions that were repressed prior to bibliotherapy. Insight occurs when the reader views their situation in a new way, and becomes motivated to make positive changes in their lives (Rozalski et al., 2010).

Parents as providers of bibliotherapy

According to Rapee, Abbott and Lyneham (2006), parents are sometimes the most

effective deliverers of bibliotherapy to children. The parent’s desire to create change in

their child can be a motivating factor. Parents have potential advantages in providing

bibliotherapy to their children (as opposed to a professional therapist) in that they have

knowledge of the child’s functioning across multiple areas, trust and rapport generally

already exist, parents often have a degree of distance from the child’s distressing

problem, and parents generally have more availability for children than does a therapist.

However, there are potential downfalls in parents delivering bibliotherapy to their

children. Parents may not be distant from the problem(s) the child is facing and could be

a contributor to the cause, the relationship between the child and the parent could be

stressed, and parents generally do not have the education and training that a therapist possesses (Rapee, Abbott and Lyneham, 2006).

Efficacy of bibliotherapy with specific diagnoses

According to Muller, Rohde, Gau and Stice (2015), depression is one of the most common psychiatric disorders experienced by adolescents. Depression experienced by adolescents is often associated with suicidal ideation, relationship issues, substance abuse, and failure in school. Efficacy trials were examined in a depression prevention group program wherein bibliotherapy was shown to reduce symptoms of depression when compared to control groups (Muller, et al., 2015).

According to Vare and Norton (2004), gay and lesbian youth face unique

challenges in today’s society. The culture of society in the United States creates

differences in the social and emotional development of gay and lesbian youth. Some

members of society exhibit fear and hostility toward these populations. A barrier of

silence exists within many schools. Gay and lesbian youth often do not see their concerns

reflected in literature, often they are not included in campus activities such as proms,

clubs, guidance activities, and special interest groups. Gay and lesbian youth currently

face a silence that alienates them from the rest of society. Bibliotherapy can be used with

youth to begin to disintegrate this barrier of silence, thereby creating a more accepting

environment (Vare and Norton, 2004).

According to Montgomery and Maunders (2015), in children ages 5-16, bibliotherapy has been shown to act on the same mechanisms as Cognitive-Behavioral

Therapy (CBT). Bibliotherapy appears to be effective in the prevention and treatment of internalizing and externalizing behaviors, and strengthening pro-social behaviors. This study showed that bibliotherapy can have a small to moderate effect on children’s behaviors. Bibliotherapy has been shown to be a financially low-cost intervention that also appears to be easy to disseminate (Montgomery and Maunders, 2015).

According to Carlbring et al. (2011), bibliotherapy has the potential to be effective in treating panic disorder. Bibliotherapy clients can be “paced,” (assigned one chapter at a time), or allowed to read an entire book if they choose. Their study examined whether pacing is generally more effective than allowing clients to read an entire book.

Results showed that pacing is not necessary when guided by a therapist. This study showed that bibliotherapy that is supplemented with telephone check-ins can have positive effects. This study also suggested that bibliotherapy has the potential to be as effective as face-to-face psychotherapy, if clients continue to read the materials and check in with her/his therapist. In this study, bibliotherapy appeared to be effective in treating people with panic disorder immediately after treatment and at 2-year follow-up.

According to Pullmann, Vanhooser, Hoffman and Heflinger (2009), treatments for anxiety in children are impractical when they depend upon consistent, in-person sessions with a family and a therapist. Bibliotherapy has the potential to fill this gap.

According to Lewis, Amatya, Coffman and Ollendick (2015), bibliotherapy may be effective in treating nighttime fears in young children. After treatment, this study showed that children in treatment generally experienced a decrease in the fear of the dark.

Nighttime fears are normal for all children, but they are considerably distressing for some. Nine children who were between the ages of 5 and 7 were studied and provided with bibliotherapy by therapists. Eight of the 9 children demonstrated a significant improvement/decrease in their anxieties. Parents reported decreases in separation anxiety, along with an increase in the amount of nights that children slept in their own beds

(Lewis, et al., 2015).

Methodology

An overview of Lewin’s Change Theory will be discussed in this section, as it was the basis for the framework for this project. The topic of how the Change Theory has relevance to this project will be discussed in this section.

Lewin’s Change Theory

Lewin’s 3-step model for organizational change begins with Unfreezing. In this initial stage of organizational change, “Lewin believed that the stability of human behaviour was based on a quasi-stationary equilibrium supported by a complex field of driving and restraining forces” (Burnes, 2004). According to Lewin, this equilibrium needed to be destabilized, or “unfrozen” prior to old behaviors being eliminated, or

“unlearnt” and new behaviors being implemented. Lewin did not believe that change would be a simple process, or that the same approach would be effective in all situations

(Burnes, 2004).

The second step in Lewin’s Change Theory is Moving (also commonly referred to as the Transition Stage). Lewin asserted that in this second stage, although Unfreezing has occurred, the prediction of behaviors is extremely difficult due to the complexities of forces involved. Lewin believed that, on a trial and error basis, one should consider the forces at work and identify and evaluate options. Lewin believed that if reinforcement were not present, change would be temporary (Burnes, 2004).

The third step in Lewin’s Change Theory is Refreezing. In this stage, the goal is to stabilize the group at a new quasi-stationary equilibrium to promote the continuum of desirable behaviors. In the stage of Refreezing, the new behavior needs to be, to a certain extent, congruent with the normal behavior, personality and environment of the learner

(Burnes, 2004). Lewin believed that successful change would need to occur on a group level. Lewin believed that group norms and activities need to undergo change for individual norms and activities to change (Burnes, 2004).

ADKAR model of change

The ADKAR model finds success in its ability to facilitate change in one person.

The ADKAR model is a framework for understanding change at an individual level

(Hiatt, 2006). This model is then extended to assist organizations such as communities, government agencies and businesses to implement change (Hiatt, 2006).

There are five concepts within the ADKAR model. These concepts are the

Awareness stage, the Desire stage, the Knowledge stage, the Ability stage, and the

Reinforcement stage. The ADKAR model is based on Lewin’s Change Theory. To illustrate, consider Connelly’s (2016) parallel between the ADKAR model and Lewin’s

Change Theory in the Reinforcement stage. According to Connelly (2016), this stage is often the most criticized area in Lewin’s Change Theory, as it is the most difficult to manage when organizations are already proceeding toward the next needed change.

However, the Reinforcement stage is essential to maintain changes and measure

20 outcomes. The individual stages of the ADKAR model and how they relate at the agency

(RC3) level will be discussed in the following section.

Awareness

In the Awareness stage, members of organizations are concerned with their understanding of the type of change, why the change is occurring, and the risks of not changing. Internal and external factors that caused the need for change are considered in this stage. Additionally, people are generally concerned with what they can personally gain from this new change (Hiatt, 2006).

Five factors affect people’s perspectives on the need for change. The first factor is a person’s view of the current state. Those who prefer the current state or deny reasons for change or discredit those who favor change. Conversely, those who see the need for change may view reasons for change as further evidence that change is necessary (Hiatt,

2006).

Within RC3, employees have unanimously supported the idea of providing bibliotherapy to clients. This may be due to the rural nature of Mendocino County, and the staff recognizing the potential value in a practice that can be implemented to serve clients who are geographically isolated. This author’s perception has been that employees are generally aware of the rural nature of Mendocino County, and that some clients are geographically isolated or lack adequate transportation. Due to this apparent awareness, the concept of implementing bibliotherapy as an intervention technique appears to be

21 generally welcomed. RC3 provides therapeutic services to clients post-crisis. As a department that already provides therapeutic services, it appears that staff are open to an additional therapeutic approach.

Desire

In the Desire stage, motivation and decision to change occur. Creating desire to change in others is difficult, as individuals ultimately make this decision. According to the Colorado Department of Transportation (CDOT, 2013), four factors affect an individual’s desire to take part in implementing a change. The first is what type of change will occur and how it will affect them. The second is the context of the organization and how change is perceived. The third is the individual’s personal circumstances. The fourth is the individual’s intrinsic motivation. Building desire within others requires that they comprehend the need for change (CDOT, 2013). According to Connelly (2016), building desire for change in others is partially accomplished by providing incentives for the individual.

This author initially recognized the need for change to occur through previous knowledge of the rural nature of Mendocino County and the geographical/transportation challenges that many clients face. Due to this awareness, the decision came naturally to this author to become motivated to implement a therapeutic practice at RC3 that could help to bridge this gap. It is this author’s belief that this same awareness prompted other employees to gain the desire to engage clients in this practice.

Knowledge

According to Connelly (2016), in the Knowledge stage, individuals gain knowledge on how to change during the transition, and how to perform when the change becomes fully implemented. According to the CDOT (2013), organizations must possess the base knowledge, for the purpose of providing it to its employees as needed. Well- planned training programs, job aides, and individual teaching assist in effectively teaching.

A literature review regarding the use of bibliotherapy when working with youth who are experiencing mental health issues was completed. Based upon the information obtained in the literature review, the bibliotherapy implementation guide was created.

The bibliotherapy implementation guide was created for use by clinicians and management at RCS. The guide aims to educate clinicians on what bibliotherapy is, the limitations of this practice, the benefits of this practice, why they may want to implement this practice, and how to implement it. Exploring web-based resources was a part of this process (see Appendix C for examples of web-based resources). This guide will be utilized to increase understanding of the goals and steps to the implementation of bibliotherapy.

Ability

According to Connelly (2016) the Ability stage is the difference between theory and practice. The abilities of individuals to effectively implement and maintain the new

23 change will vary from person to person. The performance of individuals needs to be supported through practice, coaching and feedback (Connelly, 2016). According to the

CDOT (2013), individuals must have the physical, psychological, and intellectual abilities to change. During day-to-day operations, supervisors should be involved in new changes, offering support to employees.

In this project, the bibliotherapy implementation guide was created using Google

Slides. Multiple areas of this therapeutic practice were addressed in the Google Slides presentation, including an explanation of what bibliotherapy is, the limitations of it, its benefits, why individuals may want to implement it, and how to implement it. The

Google Slides presentation is a resource that the management of RCS/RC3 can utilize to train employees on its use.

Reinforcement

According to Connelly (2016), in the Reinforcement stage, emphasis is placed upon sustaining the implemented change. Ensuring that new changes are sustained is accomplished through recognition, rewards, positive feedback, measuring performance and corrective actions. Reinforcement is essential for the purpose of sustaining change

(Connelly, 2016).

To promote the sustainability of this project, this author has provided the management of RC3 with the bibliotherapy implementation guide. This author has given the management of RC3 permission to use this implementation guide as needed. The

24 implementation guide will assist in introducing clinicians to this therapeutic technique. It is possible that newly hired clinicians could be trained on the potential benefits of bibliotherapy with this implementation guide. It is also planned for to present this implementation guide to existing clinicians at RC3. This author will be donating a bookshelf to RC3. This author has already purchased and donated multiple books for the bookshelf. This author will be donating a bookshelf to the local public library, along with books, with an emphasis on mental health content. This will help to promote the sustainability of this project, as clients can be referred there for resources.

Results

The bibliotherapy implementation guide was based on the findings of the literature review that was conducted. The following topics were included in the implementation guide: the definition of bibliotherapy, goals of bibliotherapy, benefits of using bibliotherapy when working with clients who live in rural areas, problems/gaps, process of bibliotherapy, basic rules to follow, major benefits, types of bibliotherapy: developmental and therapeutic, theoretical process, efficacy, example books, and examples of web-based resources (see Appendix B). Formatting and color choices were considerations. Because bibliotherapy is not a well known intervention, it was important to use colors, texts and formats in the guide that made it more intriguing to the audience.

Text was completed in a cyan color, along with white and black text, in an Amatic SC font, for the purpose of making the presentation visually appealing. Additionally, images were used throughout the guide to ground the information provided on each slide/page.

This author purchased multiple books online with his personal funds, and has donated them to RC3. This author purchased a bookshelf that he is donating to RC3.

Choosing books to purchase stemmed from researching online resources/suggestions for useful books. An especially helpful resource was a 2016 journal from the School Library

Journal entitled “Bibliotherapy for Teens: Helpful Tips and Recommended Fiction.” This

journal by Moulton (2014) includes recommended books organized by multiple types of

mental health disorders. This author read multiple book overviews online, prior to

26 choosing and purchasing appropriate materials. A basic internet search of terms such as

“suggested bibliotherapy books” or “bibliotherapy books for teens” will provide helpful resources.

Further research on bibliotherapy can be accomplished by reading books on the clinical practice of bibliotherapy, in addition to the books that may be provided to clients.

An excellent resource on bibliotherapy is The Novel Cure: From Abandonment to

Zestlessness: 751 Books to Cure What Ails You, by Berthoud and Elderkin (2014). This book provides helpful resources on a multitude of mental health issues.

Project phase one: Presentation of the implementation guide

Upon presenting the implementation guide to RCS management, the guide was approved for use. This author gave the agency permission to utilize this guide for training its clinicians on the use of bibliotherapy. Management informed this author that they would like him to present this guide to therapists during a meeting in the future. This author conducted a pilot presentation of the guide and resources to one clinician. This clinician stated that the implementation guide is very informative. The one criticism was difficulty in readability due to the color choices of the font. This suggestion was incorporated into the final version of the guide to provide clarity. The next step will be to present a training on this guide as a resource to the larger group of clinicians at RC3 and then RCS. Due to organizational changes that are taking place during the time of this project, the wider training will not be able to be provided until the fall. Following this

presentation and training, printed implementation guides will be provided to all

clinicians.

Project phase two: Development of resource bookshelf

The next phase of this project is to create a book lending program. This phase will be implemented at RC3, and an improved one at the local public library. This author will facilitate the donation of a bookshelf, along with relevant reading materials to the local public library. Resources that will be drawn upon in the future are community donations and potential funding from RCS for materials. Lack of available funding from the agency and lack of public awareness are anticipated barriers. A strategy to address these barriers may be to seek funding elsewhere, potentially from grants and/or other community partners. This author will provide funding for supplies if no other funding sources are available.

Conclusions

The use of bibliotherapy will never be a requirement; only an option. Since many supports in children’s lives are able to provide this therapeutic technique (parents, other family members, school counselors, school teachers), this author plans to continue to promote this therapeutic technique. The aforementioned research on the efficacy of bibliotherapy with specific diagnoses is encouraging. Bibliotherapy has a recorded history that began in 1272 in Cairo, Egypt (Jack and Ronan, 2008) and does not appear to have any less relevance to date.

Many therapists are unfamiliar with the practice of bibliotherapy. It is hoped that this project will introduce clinicians to it, and ultimately be of assistance to youth who are experiencing challenges in their lives. Bibliotherapy can help to bridge gaps, and provide mental health services to those who are geographically isolated, via telephone check-ins with a therapist.

Eventually, a physical book lending library will be implemented at RC3.

Additionally, working with the local public libraries to improve upon the accessibility and availability of relevant reading materials for youth would be of benefit to the community. This author will donate a bookshelf along with relevant reading materials to the local public library. This bookshelf will be entitled, “The Mental Health Bookshelf.”

Resources that will be drawn upon are potential funding from RC3 for materials. An

29 anticipated barrier is a lack of funding available from the agency. A strategy to address this may be to seek funding elsewhere, or this author will provide funding for supplies.

This author hopes to implement bibliotherapy into his practice when he becomes a therapist. The nature of bibliotherapy is appealing in that it allows for clinicians to provide services to those who are experiencing geographical challenges. Bibliotherapy has great potential for providing effective services to clients in need.

Sustainability

There are three main concerns around the sustainability of this project. First, developing a system to institutionalize the guide into ongoing professional development for new and continuing clinicians at RCS. Second, finding someone to take the lead on maintaining and updating this resource guide. Finally, the maintenance of the lending library bookshelves is something that will need to be addressed.

Training newly hired, and ongoing clinicians with the implementation guide has the potential to promote the Awareness, Desire, and Knowledge stages of change in the

ADKAR model. RCS currently provides ongoing trainings for new hires. There are some existing online trainings for ongoing professional development. One recommendation as a next step would be to develop an online training module that uses the implementation guide to teach clinicians how to effectively use bibliotherapy as a tool with their clients.

If that is not possible, a live training provided by management is a suggestion.

To assist in the sustainability of the maintenance of the guide as a resource, this

author has provided the management of RC3 with the bibliotherapy implementation

guide. This author has given the management of RC3 permission to use this

implementation guide at will. This author has also given RC3 permission to edit the guide

as needed. Edits can easily be made, as the guide was created in Google Slides. It is

planned for that the guide will help to introduce clinicians to a therapeutic approach that

has the potential to provide a healing approach to clients who are experiencing hardships.

The physical book lending library at RC3 will be a program that will help to

promote the efficacy of this project, as it will provide the materials necessary to conduct

this work. This bookshelf will be entitled “The Mental Health Bookshelf” (see Appendix

A for a list of example bibliotherapy books). It will also help to promote the sustainability of this project, as therapists at RC3 can refer clients there for resources. Working with the local librarian, and providing the local public library with a bookshelf will be of importance in creating a sustainable plan for updating, tracking and replacing the books over time. Maintenance of the bookshelves will occur by use of the library’s current system to track and maintain itself.

Lessons learned

When this author discussed the subject of bibliotherapy in the workplace, clinicians were unfamiliar with it. Some heard the term “bibliotherapy” and thought it was related to teaching the Holy Bible. This author was surprised that so many were

unfamiliar with this therapeutic technique. This caused this author to create a

bibliotherapy implementation guide for use at RC3/RCS. In the future, it will be of

importance to present the implementation guide to clinicians to introduce them to the

goals, problems/gaps, basic steps, basic rules, major benefits, differing types of

bibliotherapy (developmental and therapeutic), the theoretical process, and the efficacy of

bibliotherapy. Additionally, it is being considered for use in introducing school

counselors and parents on this practice.

Another lesson learned dealt with the time it requires to implement and institutionalize a new intervention in an agency setting. Because of this, there is still more work to be completed. The creation of book lending libraries needs to occur. Training newly hired staff needs to occur. Additionally, training existing clinicians on the potential benefits of this practice needs to occur. School counselors and parents may also be able to benefit from being introduced to the potential efficacy of bibliotherapy.

Future steps

The physical book lending library at RC3 is in the beginning stages of

development, as multiple books have been purchased. This author has spoken with the

program manager of RC3 who is familiar with the local librarian. This author is

interested in being introduced to the librarian. After discussions with the librarian, this

author plans to donate a bookshelf, along with relevant reading materials to the public

library for the purpose of creating a mental health section. Further education about, and

32 promotion of bibliotherapy will occur at RCS/RC3 by this author, as he develops as a therapist. This author plans to implement bibliotherapy into his own practice, as he develops as a professional therapist.

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Appendix A: Example Books for Use in Bibliotherapy

Example Books for Use in Bibliotherapy

Adoption and foster care:

Curtis, J. L., & Cornell, L. (1996). Tell me again about the night I was born. New York,

NY: HarperCollins.

Richmond, M. R. (2008). I wished for You: An Adoption Story. Minneapolis, MN:

Marianne Richmond Studios.

Zinniger, S., & Cunliffe, T. (n.d.). Yes, I'm Adopted! Sharlie Zinniger.

Aging caregivers/dementia:

Abeele, V. V., & Dubois, C. K. (2007). Still My Grandma. Grand Rapids, MI: Eerdmans

Books for Young Readers.

Shriver, M., & Speidel, S. (2004). What's happening to grandpa? Boston, MA: Little,

Brown/Warner Books.

Wallack, M., & Given, C. (2013). Why Did Grandma Put Her Underwear in The

Refrigerator?: An Explanation of Alzheimer's Disease for Children. CreateSpace

Independent Publishing Platform.

Bullying:

Johnston, M. (1996). Dealing with bullying. New York, NY: PowerKids Press.

Marcus, A. (2016). A Glass Full of Rumors: Children's Picture Book About Bullying.

CreateSpace Independent Publishing Platform.

Chemical dependency:

Black, C. (1979). My Dad Loves Me, My Dad Has a Disease: A Workbook for

Children of Alcoholics. Newport Beach, CA: Alcoholism Children Therapy.

Hastings, J. M., & Typpo, M. H. (1994). An Elephant in the Living Room.

Minneapolis, MN: CompCare Publications.

Sinberg, J. (1989). I can talk about what hurts: A book for kids in homes where there's

chemical dependency. Center City,, MI: Hazelden.

Disabilities and handicaps:

Esham, B., Gordon, M., & Gordon, C. (2008). Mrs. Gorski, I Think I Have the

Wiggle Fidgets. Perry Hall, MD: Mainstream Connections.

Martin, B., Archambault, J., & Rand, T. (1987). Knots on a counting rope. New York,

NY: H. Holt.

Divorce:

Lansky, V., & Prince, J. (1998). It's not your fault, KoKo Bear: A read-together book for

parents & young children during divorce. Minnetonka, MN: Book Peddlers.

Masurel, C., & Denton, K. M. (2001). Two homes. Cambridge, MA: Candlewick Press.

Thomas, P., & Harker, L. (1999). My Family's Changing: A First Look at Family Break

Up. Hauppauge, NY: Barron's.

Domestic violence:

Davis, D. (1984). Something is wrong at my house: A book about parent's fighting.

Seattle, WA: Parenting Press.

Holmes, M. M., Mudlaff, S. J., & Pillo, C. (2000). A Terrible Thing Happened.

Washington, DC: Magination Press.

Eating disorders:

Sachs, M. (1984). The fat girl. New York, NY: E.P. Dutton.

Grief and loss:

Brown, L. K., & Brown, M. T. (1996). When dinosaurs die: A guide to Understanding

death. Boston: Little, Brown.

Karst, P., & Stevenson, G. (2000). The Invisible String. Camarillo, CA: DeVorss

Publications.

Thomas, P., & Harker, L. (2001). I Miss You: A First Look at Death. Hauppauge, NY:

Barron's Educational Series.

Nutrition and healthy eating:

Child, L. (2000). I Will Never Not Ever Eat a Tomato. Cambridge, MA: Candlewick

Press.

Hausherr, R. (1994). What Food is This? New York, NY: Scholastic.

Llewellyn, C., & Gordon, M. (2005). Why Should I Eat Well? Hauppauge, NY:

Barron's.

Marstiller, H., & Bouthyette, V. (2010). Eat Lots of Colors: A Colorful Look at

Health Nutrition for Children. North Charleston, SC: CreateSpace Independent

Publishing Platform.

Miller, E. (2006). The Monster Health Book: A Guide to Eating Healthy, Being

Active & Feeling Great for Monsters & Kids! New York, NY: Holiday House.

O'Connor, D., & Windle, L. (2007). Andrew Potato Face. Glenmore Park,

N.S.W.: White River Design.

Rockwell, L. (1999). Good Enough to Eat: A Kid's Guide to Food and Nutrition.

New York, NY: HarperCollins.

Self-esteem:

Beaumont, K., & Catrow, D. (2004). I like myself! Orlando, FL: Harcourt.

Cook, J., & Hartman, C. (2006). My Mouth is a Volcano! (1st ed.). National Center for

Youth Issues.

Dismondy, M., & Shaw-Peterson, K. (2008). Spaghetti in a Hot Dog Bun: Having the

Courage to be Who You Are. Wixom, MI: Making Spirits Bright.

Lovell, P., & Catrow, D. (2001). Stand tall, Molly Lou Melon. New York, NY: G.P.

Putnam's Sons.

Appendix B: Bibliotherapy Implementation Guide Table of Contents

Bibliotherapy Implementation Guide Table of Contents

Bibliotherapy Defined

Goals of Bibliotherapy

Bibliotherapy with Rural Communities

Problems/Gaps

Constructive-Developmental Theory

Process of Bibliotherapy

Basic Rules to Follow

Major Benefits

Bibliotherapy: Developmental and Therapeutic

Theoretical Process of Bibliotherapy

Efficacy

Example Books

Web-Based Resources

Appendix C: Web-Based Bibliotherapy Resources

Web-Based Bibliotherapy Resources

American Library Association (ALA)

The American Library Association (ALA) provides web-based and print resources on bibliotherapy. URL: http://www.ala.org/tools/atoz/bibliotherapy

Best-Childrens-Books.com

This website provides many helpful, suggested reading materials on bibliotherapy. It specializes in bibliotherapy for children. URL: www.best-childrens- books.com/bibliotherapy.html

Bibliotherapy Education Project

The Bibliotherapy Education Project provides book reviews and resources on bibliotherapy. It discusses clinical bibliotherapy VS developmental bibliotherapy. It has a feature that allows users to browse books. The website also provides a list of websites that provide helpful resources on bibliotherapy. URL: http://bibliotherapy.ehs.cmich.edu/

Goodtherapy.org

Goodtherapy.org provides helpful information about bibliotherapy. It addresses the history and development of bibliotherapy, how bibliotherapy is used, issues treated with bibliotherapy, who offers bibliotherapy, and bibliotherapy’s effectiveness. URL: http://www.goodtherapy.org/learn-about-therapy/types/bibliotherapy

School Library Journal

This site provides a helpful list of bibliotherapy books for teenagers. URL:

http://www.slj.com/2014/11/teens-ya/bibliotherapy-for-teens-helpful-tips-and- recommended-fiction/#_