Get into Reading as an intervention for common mental health problems: exploring catalysts for change

Abstract

There is increasing evidence for the efficacy of non-medical strategies to improve mental health and well-being. Get into Reading is a shared reading intervention which has demonstrable acceptability and feasibility. This paper explores potential catalysts for change resulting from Get into Reading. Two weekly reading groups ran for 12 months, in a GP surgery and a mental health drop-in centre, for people with a GP diagnosis of depression and a validated severity measure. Data collection included quantitative measures at the outset and end of the study, digital recording of sessions, observation and reflective diaries. Qualitative data were analysed thematically and critically compared with digital recordings. The evidence suggested a reduction in depressive symptoms for Get into Reading group participants. Three potential catalysts for change were identified: literary form and content, including the balance between prose and poetry; group facilitation, including social awareness and communicative skills; and group processes, including reflective and syntactic mirroring. This study has generated hypotheses about potential change processes of Get into Reading groups. Evidence of clinical efficacy was limited by small sample size, participant attrition and lack of controls. The focus on depression limited the generalisability of findings to other clinical groups or in non-clinical settings. Further research is needed, including assessment of the social and economic impact and substantial trials of the clinical effectiveness and cost-effectiveness of this intervention.

Full text

Get into Reading as an intervention for common
mental health problems: exploring catalysts
for change
Christopher Dowrick,
1
Josie Billington,
1
Jude Robinson,
2
Andrew Hamer,
3
Clare Williams
4
ABSTRACT
There is increasing evidence for the efficacy of
non-medical strategies to improve mental health and
well-being. Get into Reading is a shared reading
intervention which has demonstrable acceptability and
feasibility. This paper explores potential catalysts for
change resulting from Get into Reading. Two weekly
reading groups ran for 12 months, in a GP surgery and
a mental health drop-in centre, for people with a GP
diagnosis of depression and a validated severity
measure. Data collection included quantitative measures
at the outset and end of the study, digital recording of
sessions, observation and reflective diaries. Qualitative
data were analysed thematically and critically compared
with digital recordings. The evidence suggested
a reduction in depressive symptoms for Get into Reading
group participants. Three potential catalysts for change
were identified: literary form and content, including the
balance between prose and poetry; group facilitation,
including social awareness and communicative skills; and
group processes, including reflective and syntactic
mirroring. This study has generated hypotheses about
potential change processes of Get into Reading groups.
Evidence of clinical efficacy was limited by small sample
size, participant attrition and lack of controls. The focus
on depression limited the generalisability of findings to
other clinical groups or in non-clinical settings. Further
research is needed, including assessment of the social
and economic impact and substantial trials of the clinical
effectiveness and cost-effectiveness of this intervention.
INTRODUCTION
Population mental health and well-being are high
on the international health agenda given the prev-
alence of depression as a major disabling illness.
1 2
Although anti-depressant medication remains the
mainstay of treatment in primary care, its effec-
tiveness has been called into question.
34
There is an
expanding evidence base in support of a range of
treatment options including psychosocial inter-
ventions and comprehensive disease management
programmes.
5e7
Within these we note increasing
interest in narrative
8
and bibliotherapeutic
9
approaches, which typically emphasise the impor-
tance of meaningful social engagement; a sense of
value, purpose or comprehensibility in respect
of one’s self and life; a sense of agency and of
manageability in relation to the problems and
demands posed by life; and the capacity to “tell
a good story about oneself ”.
10e12
As the last
possibility is likely to decrease in the culturally
adverse setting of an in-patient ward, or in the
context of a diagnosis which offers a passive story
of a ‘patient’who is ill and in need of professional
cure, recent initiatives have stressed the importance
of preventive interventions which can reach
individuals before such adverse personal stories
take hold.
Get into Reading
The principal feature of the Get into Reading (GiR)
model is shared reading of serious literature within
a group setting. ‘Serious’is used in preference to
‘classic’which risks confusion with ‘classical’(ie,
Latin/Greek) literature. The term has a long
historydThe Oxford Professorship of Poetry was
established for “the advancement of more serious
literature both sacred and human”
13
dand is widely
used by writers and literary critics to distinguish
literature that addresses important human
issues, such as those concerning social and moral
behaviour, from, for example, ephemeral writings
(comics, popular magazines) and genre fiction (eg,
detective novels, ‘chick lit’).
All material is read aloud in the session itself and
open-ended discussion is encouraged by the facili-
tator. Group members participate voluntarily as
they wish and interact in relation to what is
happening in the text itself (in terms of narrative,
characters, place and setting, themes, description
and language, for example) and what may be
happening within themselves as individuals (in
terms of reflections about personal feelings and
thoughts, opinions and experiences, for example) as
an articulated and evolved response to the shared
reading of the text and wider group discussion.
GiR sessions last for 90 min, and their basic
structure is summarised below:
Break-In/Re-cap Period (10 min)
Prose Reading and Discussion (50e60 min): the
facilitator always begins the session by reading
aloud from a short story or novel. Group members
are free to interrupt during the facilitator’s reading
if they want to raise questions or express opinions,
but if not interrupted the facilitator will usually
pause after four pages (approx 8e10-min reading
time) of the short story or novel at an appropriate
point to encourage discussion and allow time for
group reflection. In these pauses, the discussion can
range widely, usually starting with issues, charac-
ters or situations contained in the material just read
and often progressing to personal reflection and the
sharing of opinions and experiences. After a time
the facilitator will bring the discussion back to the
<An additional appendix is
published online only. To view
this file please visit the journal
online (http://mh.bmj.com/
content/38/1.toc).
1
Department of Mental Health
and Behavioural Sciences,
University of Liverpool,
Liverpool, UK
2
Department of Sociology,
University of Liverpool,
Liverpool, UK
3
School of English, University of
Liverpool, Liverpool, UK
4
The Reader Organisation,
Liverpool, UK
Correspondence to
Professor Christopher Dowrick,
Department of Mental Health
and Behavioural Sciences, 1st
Floor Block B Waterhouse
Buildings, University of
Liverpool, Liverpool L69 3GL,
UK; cfd@liv.ac.uk
Accepted 15 January 2012
Published Online First
18 February 2012
Med Humanit 2012;38:15e20. doi:10.1136/medhum-2011-010083 15
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text and ask if anyone would like to take a turn reading. A group
member might volunteer and the same pattern will be
repeateddthe group member pausing or handing over the
reading aloud or the facilitator intervening to allow discussion or
another group member to take a turn.
Poetry Reading and Discussion (20e30 min): the session always
concludes with a reading of a poem. The poem is often selected
to reflect or develop themes that might have been read about
and discussed during the session in response to the prose
material. The poem is intended to restore a sense of balance to
the mood of a group, which can prove particularly helpful in
circumstances where the group has been reading a difficult
episode in the story. The poem also provides an opportunity
for members who may not have read during the prose section of
the session to take a turn at reading aloud. After several readings
and discussions, the facilitator will usually ask for one final
reading of the poem to conclude the session and to illustrate
how far the group members may have come in their
understanding of the piece.
End of session: group members leave the designated reading area.
Previous research into GiR
The findings from earlier research are that GiR is a feasible and
acceptable intervention for a variety of health conditions within
both primary care and specialist settings.
14
General practitioners
(GPs) are supportive of GiR and its benefits, in particular for
patients who frequently consult on poor mental health linked to
social isolation, and for whom GPs often feel unable to offer
conventional medical treatments. Such patients are not just
poor in the sense of materially deprived, they are also ‘word
poor’and may lack the resources to be able to communicate
their day to day concerns to their GPs.
15
Prior to this research, observed and reported outcomes for
participants included being ‘taken out of themselves’via the
stimulation of the book or poem; feeling ‘good’,‘better’or ‘more
positive about things’after taking part in the group; valuing an
opportunity and space to reflect on life experience, via memories
or emotions evoked by the story or poem, in a convivial and
supportive environment; improved powers of concentration;
a sense of common purpose and of a shared ‘journey’; increased
confidence and self-esteem; a sense of pride and achievement;
valued regular social contact; and improved communication
skills.
15
These preliminary findings resonated with other innovative
research into reading and health, which suggested that the act of
reading together a literary text not only harnesses the power of
reading as a cognitive process, but also acts as a powerful socially
coalescing presence, allowing readers a sense of subjective and
shared experience at the same time.
16
Related research suggested
that the inner neural processing of language when a mind reads
a complex line of poetry has the potential to stimulate existing
brain pathways and to influence emotion networks and memory
function.
17
The focus of this paper is an exploration of catalysts of change
in GiR groups. We consider evidence to indicate the therapeutic
importance (or otherwise) of three potentially influential
factors:
<Literary form and content
<Facilitation
<Group processes.
We focus on literary form and content because these are at the
heart of the GiR experience. The intervention is predicated on
the assumption that serious literature offers a model of, and
language for, human thinking and feeling with the potential to
‘find’and alleviate personal trouble and thus to produce thera-
peutic benefits. This view of literature, as being health-
promoting in the widest human sense, has a long and strong
lineage in literature and in literary-philosophical theory: from
Aristotelian catharsis, through the Renaissance tradition of
poetry’s morally redemptive and emotionally alleviating func-
tion, to the Victorian commitment to the democratisation of
culture as an ennobling and life-supporting influence.
18e21
This
tradition has been resurrected in recent decades by literary
scholars, psychologists and health practitioners who argue for
the healing effects of reading fiction and poetry, emphasising
literature’s capacity to put humans in touch with, and help
them articulate, implicit and inchoate aspects of personal
experience.
22e24
These studies intersect with philosophical
and psychoanalytic traditions emphasising the importance of
having a language to express complex experience as a means of
tolerating and surviving it.
25e30
We have already noted experiential evidence to support these
theories in relation to GiR as a specific literary intervention.
15
Facilitation by someone with expertise both in the key subject
matter and in education (using the latter term in its literal sense
of ‘bringing out what is within’), and the potential benefits of
sharing reflections and responses with others in a group setting,
are both procedures with established therapeutic provenance,
20
and hence likely to be reproducible in this setting.
METHODS
Two open weekly community reading groups were established,
in a GP surgery and a mental health drop-in centre, for people
with a GP diagnosis of depression and a validated measure of
severity (Patient Health Questionnaire (PHQ-9)).
31
Participation
was voluntary and the criterion for inclusion in the group was
a validated diagnosis of depression (ie, a PHQ score of 10 or
more); note was taken of other medical/psychiatric diagnoses,
but there were no other specific exclusion criteria.
Data collection
Data collection took place over a 12-month period between July
2009 and July 2010.
Quantitative data
Questionnaires for participants were administered before and
after the GiR experience. These included PHQ-9 scores and self-
report information regarding the use of healthcare services
(consultations, prescriptions, referrals to secondary care).
Observation and reflective diaries
To capture the interaction taking place within the reading group
sessions, we made digital recordings of all sessions. Two
members of the research team (JB and JR) each observed one GIR
group per month. They and the facilitator (CW) also completed
reflective diaries of the group reading sessions.
Analysis and interpretation
Quantitative data were analysed by CD using the standard
descriptive and statistical methods packages contained within
SPSS V.15.0 for Windows.
32
Digital recordings of each session were transcribed using
appropriate annotation to prepare the text for conversation
analysis (AH), which included studying speech events, such as
turn-taking, interruptions, participation and silences, in relation
to the immediate setting and stimuli, the poems presented to
the participants and the wider social context of the reading
group.
33
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Other data sources, including the observation notes and
reflective diaries of the researchers and group facilitator, were
used to enhance, corroborate, question and/or contradict the
ongoing analysis of the transcripts and the quantitative data. A
detailed thematic analysis of the transcripts was used to identify
additional components of the intervention, specifically the social
dynamics created by group process and the facilitator ’s role in
promoting communication.
34 35
A literary researcher (JB) and a linguist (AH) used the
data collected via digital recording/transcription to study the
‘cross-hatch’between participant responses, as established by
conversation analysis, and the literature in terms of: the human-
emotional content of the poetry and fiction; the role of the
facilitator in guiding emotional and intellectual responses to the
literary stimuli; and the role of the group process in encouraging
the articulation of personal thoughts and feelings in relation to
the fiction or poetry.
36
Ethics and safety
The project was approved by the Sefton NHS Research Ethics
Committee (ref 09/H1001/45) and conducted according to the
principles of good research governance. If any participant
displayed suicidal or violent ideation during a meeting, a senior
professional was available within the host organisation (a
trained psychologist in the drop-in centre, a GP in the primary
care setting) for immediate consultation.
FINDINGS
At baseline, 18 GiR group participants provided quantitative
information and 14 of these supplied complete information.
Most participants were aged between 35 and 64. There were
similar numbers of men and women and all considered them-
selves to be white. Fourteen attended the reading group at the
mental health drop-in centre. All participants had been in
contact with their GP in the previous 6 months, most
commonly between three and six times, while half had hospital
contact once or twice during the same period. Everyone reported
taking at least one regular medicine. The mean PHQ-9 score was
14.3, which is equivalent to a diagnosis of moderate depression.
Despite our formal cut-off of a minimum PHQ-9 score of 10,
two participants had initial scores of <10.
At follow-up, eight (44%) participants provided updated
information on healthcare use and PHQ-9 scores. There was no
significant difference in mean baseline PHQ-9 scores between
continuing participants and those who dropped out, and
demographic proportions were similar at baseline and at follow-
up. The evidence suggested a reduction in depressive symptoms
for GiR group participants. Six of the eight follow-up respon-
dents had PHQ-9 scores below 10 (the accepted level for
depression caseness) compared with only two of 17 at baseline
(Fisher’s two-sided exact test, p¼0.0036). Analysis of the change
in mean scores for those with initial PHQ-9 scores of 10 or above
(n¼6) indicated that the initial mean (SD) score was 16.0 (4.6)
and the follow-up mean (SD) score was 11.2 (9.0) (Student
t test, two-tailed p¼0.0565). There was no trend towards
a reduction in mean numbers of GP or hospital contacts or
regular medications over time.
We explored three potential catalysts for change: literary form
and content; facilitation; and group processes. We also noted
influences of the physical environment.
Literary form and content
GiR groups are exposed to a rich, varied, non-prescriptive diet of
serious literature with a mix of fiction and poetry. The former
appeared to foster relaxation and calm, while the latter
encouraged focused concentration. Both literary forms allowed
participants to discover new, and rediscover old or forgotten,
modes of thought, feeling and experience. The full set of literary
and poetic texts used by both reading groups can be found in
supplementary online appendix 1.
The continuous narrative found in works of fiction tended to
lead to observed and self-reported outcomes of relaxation, or
calming of mental anxiety. One participant (an avid readerd“I
used to eat books”dbefore his wife’s long-term illness led to his
“not being able to concentrate on anything but TV”) described
with surprise, at the close of the first session he attended, how
the story had “soothed”him “here”(pointing to his forehead).
Such soothing effects of story were particularly visible in
another participant who, during the poetry reading at the start
and close of the session, had been easily distracted (fidgety in
body, eyes and head, and excessively aware of the attention and
behaviours of other group members) but became stilled as her
absorption in the story overcame other claims on her attention.
The relaxation enabled by story is perhaps specifically related
to narrative’s mode. Unlike lyric poetry, which exists ‘outside’of
time, narrative moves in a continuous temporal sequence, and
this ‘fictional’time can be picked up, re-joined and eased into
again after a break for discussion, or after the week-long gap
which separates one session from another. The sense of relaxa-
tion and the repeated comment from participants that ‘it takes
my mind off other things’might be related to the fact that, in
narrative in temporal terms at least, if not in terms of the
reader’s‘production’of the text,
25
the future takes care of itself.
Certainly this narrative time overrode any interruption in real
time: people entering the room or noises outside were collec-
tively ignored unless attention was directly claimed. The intense
absorption was closer to meditation than escapism since group
discussion continually touched base in real time and with real
personal experience.
Poetry, on the other hand, was demonstrably more exacting
regarding levels of concentration and mental effort and elicited
more verbal expression of thinking, intensity of focus on indi-
vidual words and meanings and, interestingly in light of
increased difficulty, inclusiveness. There was a tendency for
participants to go back to and repeat aloud words, phrases or
lines in an effort to understand or mine for meaning and the
emphasis in the main was on finding meaning for its own sake
rather than relating it to personal experience. This tendency can
be seen in the following example of discussion between partic-
ipants A and L (with facilitator F) on Louis MacNeice’s poem
Snow (words in italic are text from the poem itself):
A: The drunkenness of things being various. It is a strange one.
L: Yes. I think it’s about Christmas though, as you say, definitely,
isn’tit?
A: Or,
L: Don’t know what to make of it, what do you make of it?
A: And the fire flames and the bubbling sound for words, worlds, bubbling
sound for worlds, is more spiteful and gay than one supposes.
L: I mean they don’t sort of go together really do they?Spiteful and
gay.
A: No
F: No
L: Sort of opposites.
It was observed that participants who never offered to take
a turn reading narrative often accepted the invitation to read a
poem. The poems’relative brevity (perhaps not so daunting as
a long paragraph of prose) was an influence here. Individual
confidence also seemed engendered by the mode of discussion
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characteristically elicited by the poems, where much more
verbalised collective meaning-making was evidentdeverybody
working out the poem together, as if it were a puzzle (or
‘conundrum’as one participant would often put it).
Facilitation
The group facilitator had roles in expert choice of literature, in
making the literature ‘live’in the room and become accessible to
participants through skilful reading aloud, and in sensitively
eliciting and guiding discussion of the literature. The facilitator’s
social awareness and communicative skills were critical in
creating individual confidence and group trust and in putting the
group’s needs above those of the individual where necessary. The
facilitator’s alert presence in relation to literature, the individual
and the dynamics of the group is a complex and crucial element
of the intervention.
Literary knowledge and expertise were observed to be essential
both in making available suitable choices of reading material and
in offering an approachable but credible authority on literature
that people could question and query. In addition, the facilita-
tor’s skill as an expressive reader was key in making the litera-
ture ‘live’in the room and creating an atmosphere of serious
attention. The facilitator’s further expertise as an interpreter of
narrative and of poetry was crucial in holding, and holding open,
key ideas or central concerns, often by returning the discussion
to tiny details of the poem or story and repeating individual
words, lines or sentences.
F.this second bit of the poem, the second stanza, that is
interesting though as well isn’t it, because it’s still going on about
this idea of stillness, but as if there are things happening
underneath the stillness, so you know this going back, these theme
of ice, I don’t know, as if there is the ice but then there is this
current underneath, I don’t know.
M: The undercurrent to something, and it’s, whatever it is has got
to come up to the surface, do you think?While you are talking.
F: Because he says we know the current is there, hidden. That is
interesting this idea that we know, there is great sort of reassurance
in that line would you say, we know, we most probably don’t know
a lot of things do we, but we know, the current is there, hidden
though, but it seems to accept that.
M: Wants something to come, to bring it out, yes.
A further aspect of the facilitator ’s literary expertise was the
ability to capture details of participant contributions which
helped whole group understanding. In this example the facili-
tator picks up participant Eddie’s instinctive and initially quiet
repetition of words from the poem (in italics) and uses it as
a tool for the rest of the group to keep in focus a key phrase of
RS Thomas’poem The Moor: “It was like a church to me”:
F: If we just take the very first, maybe we will work with the very
first sort of few lines, when he says, It was like a church to me.
E: I entered [it] on soft foot.
F: Soft foot. That is interesting, isn’t it Eddie?
M: You feel when you went in a church you sort of, you know,
tiptoe in don’t you, you don’t just sort of just go marching in like
you do into a supermarket or something.
D: You have got to go in quiet.
M: Yes. You do.
F: What’s that about that going in softly then?
M: Well
F: What’s that about?Is it going in on tiptoe?
M: It’s all quiet
I: Not disturbing anything.
F: Not disturbing anything.
I: Yes
F: It was like, so it’s not actually a church, It was like a church to me.
Group processes
The role of the group was to offer support and a sense of
community and this was supported by the accounts of the
participants themselves. The latter was fostered particularly by
the shared reading model of GiR which includes everyone
together in the reading experience. Likewise the discussion
elicited in response to the texts, where personal ideas, feelings,
opinions and experiences were mutually shared, was demon-
strably critical in ‘knitting’the group together.
Linguistic analysis of the groups’conversational habits over
the 12 months shows a clear increase in reflective mirroring of
one another’s thought and speech habits, as well as greater
cooperation and confidence, as participants took the initiative in
supporting one another’s comments, in guiding the direction
of discussion and in offering to read aloud from the text
themselves.
Verbatim or near-verbatim repetition of another participant’s
words shows that the speaker’s attention is closely focused on
the conversation, and that they wish to support the view the
other has expressed. In the following example, in which the
group are discussing Laurie Lee’sCider with Rosie, M repeats two
words (“took him”)ofA’s utterance. A corrects her, and supports
her own first utterance, by repeating both her earlier salient
points. At the same time, however, she repeats M’s“she just
took him”. The repetition of M’s words acknowledges M’s point
of view and softens the correction:
A: And they used him as a battering ram, and he come back
absolutely penniless, and then this girl from the district, Fanny,
Fanny took him and married him
M: [laughs] Yes, yes, yes, I don’t think there was ever nothing said
about love, she didn’t fall in love with him, she just took him.
A: No, she just took him took him and married him.
Syntactic mirroring is another means or indication of
a speaker supporting another participant’s viewpoint. In the
following example, where the group are reading Mitch Albom’s
novel Five People Who Meet in Heaven,R’s syntactic structure is
twice mirrored by L.
R: Either you are responsible for your fate or you are not.
L: Either you believe or you don’t believe.
F: I wonder if they are two different things there, because partly
L: (interrupt) Either you believe in God or you don’t believe in God.
In the next example, again from the discussion of the poem
Snow, A ponders the meaning of the poem, then, with the
comment “oh, strange”, shifts out of the discussion of the text
and creates a new world, warm and pleasant. L immediately
joins her in this fantasy world, and mirrors A’s syntax as she
does so:
A: What’s going on and maybe Christmas, maybe just a sudden
downfall of snow. Oh, strange. Light the fire, get everything nice
and warm.
L: And sit and look out. Out on the world with the snow coming
down.
This discussion was at times intense, bursting with the
simultaneity of thoughts, worlds and realities:
L: More than one thing happens from. You can just imagine
yourself being there can’t you?
A: Yes.
L: The snow coming down.
A: Yes. Snow us another tangerine [laughs].
L. And the pips.
A: Spitting the pips in the fire.
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L: Sitting there in front of the fire, peeling a tangerine.
A: Peeling a tangerine, splitting it up, and the pips in the fire.
L: You can just think of that. You can just imagine that really.
Analysis of the rhythm and intonation of the utterance
“Snow us another tangerine”shows that this playful literary
metaphor can also be set to music (the ‘tune’represented by
musical notation as shown in figure 1), reflecting A’s exuberant
‘singing-out’of the dissolving of boundaries between selves and
worlds.
At other times, there were signs that group members were free
to pursue individual and personal trains of thought, enabled by
the protective presence of the group. “Do you think he feels as
though it’s, there is like a magic to that just that moment, it’s
magical”, asks L in response to Snow.“You would rather have
that place, than a church as well”, was one participant’sreflec-
tion on The Moor. Separated, divergent lines of thought, or
‘personal’narratives of meaning often surface and, from time to
time, converge with the group discussion. But they are
demonstrably continuing intently beneath the surface of the
latter and are indicative of subterranean concentration over
a long time span on particularised matters.
These factors and processes are known to be influential in
enabling therapeutic effectiveness in group settings, and have
been described by Yalom in his analysis of interpersonal group
psychotherapy. The instillation of hope and the development of
cohesiveness are key ingredients here. Syntactic mirroring, for
example, is closely linked to Yalom’s concept of imitative
behaviours.
37
Physical environment
The physical environment contributed to the atmosphere, group
dynamic and expectation of the utility of the reading group. The
group which met at the mental health drop-in centre was easier
to recruit, and was much more willing to engage with the
literature for its own sake from the very outset of the study. By
contrast, the group which met at a GP surgery initially tended to
view the literature as something ‘prescribed’to them in direct
relation to their mental health problems. The location of the
latter reading group in (often different) doctors’offices may have
encouraged this perception, where the former reading group had
a designated and more informal space for the group each week.
However, while the environment influenced the group, the
collective action of the literature, facilitator and group appeared
to supersede that of the environment. The creation of a stimu-
lating, non-pressurised, non-judgemental atmosphere (“not like
school”, as one participant emphatically put it) overrode
considerations of physical environment.
DISCUSSION
In this study we have found qualitative evidence indicating that
three core componentsdshared reading of literary texts, skilled
facilitation and social group processesdmay be important for
any therapeutic efficacy that GiR possesses. We consider that the
focus on literary texts specifically, and the combination of these
three components generically, are unique to the GiR model.
With regard to the literary content, we found that narrative
texts tended to encourage reflection and relaxation, as within
this format the future tends to take care of itself, whereas
poetry, which is intentionally more immediate, was more likely
to evoke participation and active social engagement. The
combination of these responses appears to be valuable in
reducing key symptoms of depression, such as anhedonia,
difficulties with concentration and personal withdrawal.
It was easier to recruit participants in the mental health drop-
in centre than in the primary care setting, suggesting that the
former may be a more feasible venue for this type of interven-
tion. Our quantitative findings indicated possible therapeutic
benefits for participants, but did not indicate any clear pattern of
change in health service use: this may suggest that the impact of
GiR is mainly at a personal level, in terms of a reduction in
negative self-images or stories.
This study has four main limitations. First, its design was
such that we are unable to offer more than suggestive evidence
of the therapeutic efficacy of GiR groups as an intervention for
depression, given the small sample size and the lack of either
standardised diagnostic interviews or control groups. Second,
less than half of the original participants provided follow-up
information: it is possible that those who left the group had
more negative experiences of participation than those who
remained. Third, we did not collect information on other
modalities of psychotherapy in which participants may have
engaged. Finally, the focus on participants with depression
means that insights into the catalysts for change in GiR groups
may not be generalisable to other clinical groups for whom GiR
has been offered (eg, people with dementia) or in educational,
forensic or other non-clinical settings. In these contexts it is
possible that other change processes come into play.
GiR groups are becoming increasingly popular in both clinical
and non-clinical settings. There is therefore a pressing need to
subject them to rigorous analysis in a number of dimensions,
before healthcare policy makers, commissioners and clinicians
can have confidence in recommending their introduction into
routine healthcare.
We have indicated that proof of concept, feasibility and
acceptability studies have already been undertaken. In this study
we have identified potential GiR catalysts for change in the
context of common mental health problems. Further work is
needed to elucidate these processes in greater detail, deploying
further methodological approaches in addition to linguistic
analysis, and using interview and focus group data gathered
from study participants. Important next steps include exami-
nation of evidence of the social and economic impact of GiR
groups, using before-and-after study designs, and comparison of
catalysts for change for patients with other common conditions
such as dementia. All of this research should then lead towards
substantive effectiveness and cost-effectiveness studies based on
randomised controlled trials of GiR groups in comparison with
evidence based interventions including adequate attentional
controls.
Acknowledgements We are grateful to the staff of Upstairs at 83 and of the
Aintree Park Group Practice for hosting and facilitating the reading groups that form
the basis of this study. We are immensely grateful to the people who took part in
these reading groups, for sharing their time and experiences with us.
Contributors CD, JB, JR and AH conceived the study and submitted the proposal for
funding and ethics approval. CW, JB and JR collected data. CD analysed quantitative
elements of the study. JB, JR and AH analysed qualitative elements of the study. All
authors made substantial contributions to the substance of the paper, including critical
amendments to drafts. All authors approve the final version.
Funding This study was funded by a grant from MerseyBeat/Liverpool Primary
Care Trust.
Figure 1 The tune for “Snow us another tangerine”.
Med Humanit 2012;38:15e20. doi:10.1136/medhum-2011-010083 19
Original article
group.bmj.com on January 25, 2016 - Published by http://mh.bmj.com/Downloaded from

Competing interests None.
Ethics approval Ethics approval was provided by Sefton NHS Research Ethics
Committee (ref 09/H1001/45).
Provenance and peer review Not commissioned; externally peer reviewed.
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Original article
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catalysts for change
common mental health problems: exploring
Get into Reading as an intervention for
Clare Williams
Christopher Dowrick, Josie Billington, Jude Robinson, Andrew Hamer and
doi: 10.1136/medhum-2011-010083
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