Scandinavian Journal of Occupational Therapy. 2015; 22: 62–71
ORIGINAL ARTICLE
Reading fiction during sick leave, a multidimensional occupation
LENA MÅRTENSSON & CHRISTINA ANDERSSON Institute of Neuroscience and Physiology/Occupational Therapy, Sahlgrenska Academy, Göteborg University, Göteborg, Sweden
Abstract Background: In bibliotherapy, the therapeutic gains of reading fiction are ascribed to the literature. Viewing reading fiction as an occupation may give other explanations of its therapeutic function. Aim: The aim of this qualitative study was to explore the experiences of reading fiction among women during a period of sick leave. Material and methods: A qualitative approach was applied. Eight women who had been reading fiction during sick leave were interviewed. Results: An overarching theme: Supporting one’s active self, comprised five categories of experiences: a prospect of ordinary life, a place of refuge, a life together with others, a source of power, and as supporting an active life. Conclusion and significance: Based on the categories, reading fiction is seen to comprise intentional, functional, mental, relational, and personal dimensions. A tentative model of supporting one’s active self is proposed, which may be helpful in clarifying the mechanisms of the process of change. The health-related dimensions of reading fiction suggest that reading fiction should be regarded as a significant occupation comparable with other, more highlighted ones. Understood in this way, it is argued that the results add to the knowledge base in occupational therapy focusing on how meaningful occupations connect to occupational life trajectories.
Key words: qualitative research, occupational dimensions, Bibliotherapy
Introduction The use of literature to improve people’s mental health goes under the name of bibliotherapy (1) in the treatment of persons with emotional disorders such as depression and anxiety (2-4). In this therapeutic form, it is considered that the gains of reading fiction are ascribed to the interaction between the reader and the literature (5). A systematic literature review (6) showed that bibliotherapy is cost effective as support in treating different forms of psychological ill health. However, there is no evidence for how the use of literature contributes to increasing mental health. A suggested explanation for the therapeutic power of reading is that it has the function of a fictive friend or support group and that it gives the possibility to become absorbed and to escape from problems (7).
Viewing reading fiction as an occupation may give other explanations of its therapeutic function, as the meaning component of occupations is considered to be an important factor when discussing the relationship between occupation and health (8,9). If fiction reading is a habitual occupation before the onset of illness, it may validate unaffected abilities and capacities during times of illness and thereby contribute to a view of self as a healthy and competent person. Being confirmed and recognizing oneself, which are important aspects in therapeutic reading (10), have been shown to be significant forces in rehabilitation in, for example, long-term pain conditions (11). Based on the structure of the Value and Meaning of Occupations Model (ValMO) (12), there are potential values inherent in any single occupation. Thus, the occupation of reading fiction may include concrete, symbolic, and self-rewarding values that may explain
Correspondence: Lena Mårtensson, PhD Reg OT, Institute of Neuroscience and Physiology/Occupational Therapy, PO Box 455, SE 405 30 Göteborg, Sweden. Tel: +46 703 336948. Fax: +46 31 786 5723. E-mail: [email protected] (Received 15 April 2014; accepted 13 August 2014) ISSN 1103-8128 print/ISSN 1651-2014 online 2015 Informa Healthcare DOI: 10.3109/11038128.2014.955877
Reading fiction during sick leave the efficacy of this occupation in times of ill health. The dimensions related to occupation comprising meaning in the form of doing, being, becoming, and belonging (13,14) may also be applicable to the occupation of reading fiction. Besides the possibility to have something relevant to do, reading fiction may be seen as an opportunity to achieve a state of being by becoming absorbed in a fictive world. It may also lead to gaining the social role as a reader, with its relevance for belonging in contexts where reading fiction is a key for inclusion. It seems important to explore the reasons for reading fiction as an occupation, and its benefits for persons with health problems, based on an occupational perspective, as there is in principle no research based on this perspective. A search in the Scopus database with the search combination “occupation” AND “reading fiction” OR “bibliotherapy” in the title, abstract or key words resulted in six titles published between 1975 and 2014, of which four were written in English (15–18). Of those, one literature review compared a cognitive intervention with different kinds of therapies, e.g. bibliotherapy and occupational therapy (15). In the other ones the concept occupation was not mentioned at all, or was not applicable to the occupation reading fiction. Expanding the focus on reading from being a therapeutic tool to investigating how engagement in reading is experienced as being linked to different aspects of everyday life could contribute to further explaining the presupposed association between occupation and health (14,19). The aim of this study was to explore the experiences of reading fiction among women during a period of sick leave. The reasons for focusing on women’s therapeutic reading are several. Women read more than men (20). Furthermore, women are more absent from work due to illness than men (21) and mental illness, for which reading fiction is most often used as therapy, is a more common reason for sick leave among women than men (22,23).
Material and methods Design and setting The study had an exploratory and qualitative design, as the aim was to gain and describe new knowledge. A hermeneutic approach was applied to capture the subjective experiences of reading fiction during sick leave. The study was carried out in a town with > 500 000 inhabitants, in the south-west of Sweden, and the research plan in its entirety was approved by the Regional Ethical Review Board in Gothenburg (Dnr 249-11). Both authors are registered occupational
63
therapists without any experiences of using bibliotherapy as a tool in practice. Participants The participants were recruited by purposeful sampling (24). Flyers with brief information about the study were strategically placed in bookshops, libraries, educational associations, health activity centres, etc. The flyers included a web address for a homepage with detailed information about the study and participation. There was a link on the homepage for visitors who were interested in participating to contact the researchers. Criteria for participation were: . . . . .
Woman of working age who was or recently had been on sick leave for at least three months. A physical or mental condition as the reason for sick leave. Ability to read hard-copy books or listen to audio books. Reading at least one book a month during the sick leave. Ability to understand and speak Swedish without the assistance of an interpreter. The exclusion criterion was:
.
A sick leave period concluded more than 12 months before recruitment.
Ten women showed interest in participating. They were contacted by telephone to give verbal information about the study’s aim and the interview method, as well as to ensure that participation was voluntary and that no unauthorized person would gain access to the research material. Two of the women that showed interest were excluded as they did not fulfil the criterion of ongoing or recent sick leave. Thus, the study included eight women of various ages. For all eight participants, reading fiction was a lifelong interest and, for all of them, there was a time early in the sick leave period when reading was not possible because of the demands it places and the fact that their focus was on simply surviving or living from day to day. The authors did not have any kind of relationship with the participants. The demographics of the participants are given in Table I. Data collection The interviews were carried out using an interview guide that included different aspects of reading fiction during a period of sick leave. The open-ended interview questions served as a general basis for reaching more specific and deeper questions on different factors.
64
L. Mårtensson & C. Andersson
Table I. Demographics of the eight participants (A–H).
Profession
Reason for sick-leave
Sick leave duration (months)
Reading frequency during sick leave (books per month)
Participant
Age (year)
A
34
Student
Cancer
6
4
B
39
Journalist
Post-traumatic stress
7
4
C
40
Librarian
Cancer
4
4
D
42
Teacher
Burn-out depression
7
6
E
44
Social worker
Burn-out depression
4
4
F
26
Personal assistant
Psychosis
16
2
G
52
Self employed
Burn-out depression
36
1
H
67
Physiotherapist
Cancer
9
1
The interview guide included questions like: How would you describe your interest in reading fiction? As an occupation, how important is reading fiction for you? What are your experiences of reading during your period of sick leave? Is it different from your ordinary reading? Do you connect reading fiction during sick leave with any kind of value? Does reading fiction influence you in any way during sick leave, physically or mentally, in performing activities and in social participation? Based on inspiration from Grounded Theory (25), a brief analysis was carried out after each interview to gain an overall understanding of the experiences and to develop new questions in the subsequent interviews. Each participant was interviewed once. The interviews were carried out in places chosen by the participants. Four of them took place at parlour rooms at a university, three in the participants’ homes, and one on Skype. It was attempted in the interviews to maintain a balance of power, concerning preferential right of interpretation and meaning of concepts and words from both parts. This form of reflexivity was promoted by performing the interviews in a relaxed way, so that it was more like a conversation than a formal interview, and by letting the interviewees react to perceived meanings. The interviews, which were digitally recorded, lasted from 60 to 90 minutes. Analysis Content analysis as described by Graneheim & Lundman (26) was used to reach qualitative descriptions of the women’s experiences of reading fiction during sick leave. The analysis process started with a word-by-word transcription (in Swedish) of each interview after its completion. All of the interviews were read through several times to obtain a sense of the whole. The texts that concerned the experiences of reading fiction were then extracted and brought together. This
text constituted the unit of analysis. The next step was to divide the text into meaning units that were condensed. The condensed meaning units were then abstracted and coded on the basis of their inherent meaning (26). In concrete terms, this was done by continuous discussion between the authors regarding possible inherent meanings and by contextualization of the meaning units in the individual interviews and in the data as a whole (27). The new questions formulated, based on the brief analysis after each interview implied a gradually deeper understanding of the meaning of the phenomenon studied. The next step involved comparing the codes based on differences and similarities in order to distinguish patterns of experiences (26). Reflexivity was considered both by maintaining awareness of the professional preunderstanding and by looking for multiple interpretations of the experiences described. The patterns that emerged were arranged into 12 tentative categories, which constituted the content. These were reflected on and discussed by the authors. The discussion between the authors resulted in agreement on the structural patterns of the tentative categories; based on their similarities and differences, five qualitative categories representing different aspects of meaning finally emerged. The categories were compared with the empirical Swedish raw data, i.e. the transcribed interviews, in order to test the trustworthiness of the emerging categories. The final step of the analysis included a discussion about the underlying meaning, the latent content of the categories (26). This resulted in a theme representing the experience of reading fiction during sick leave as supporting the women’s active selves. Both authors were involved in all parts of the analysis, and there was continuous discussion between the authors at every step of the process concerning the interpretations and possible meanings, based on reflection on previous knowledge – professional knowledge and that acquired by experience.
Reading fiction during sick leave Results Five categories emerged, representing different experiences of the occupation of reading fiction during sick leave. Significant citations are given for each category, followed by a letter in brackets (A–H), indicating the participant being quoted. The categories are termed: a prospect of ordinary life, a feeling of capability, a place of refuge, a life together with others, and a source of power. An overarching theme, “supporting one’s active self”, covered the underlying meaning of all the categories as well as the relations between the categories. A prospect of ordinary life This category describes reading fiction as a means to regain an ordinary life, as life is not experienced as it used to be without reading fiction. The category comprises three subcategories. Filling the gap. Due to the meaning associated with reading fiction, the involuntary “reading break” during the first part of the sick leave means that a substantial part of life is missing. Reading fiction is deliberately chosen to fill this gap in daily life. Compared with other occupations, reading fiction is experienced as being associated with small demands and, as such, as a valuable, meaningful, and harmless compensation for other, unrealizable, occupations. The urge to recapture the ability to read fiction is also based on a desire to fulfil the ordinary self-image as a reader. Reading has been extremely important not to be trapped in the little igloo you’re in when you’re on sick leave . . . you’re a little screened from reality in a way . . . you’re not in the loop . . . you look through the window, and it’s there that life is going on, but when I read I get outside that and simply get another dimension of the world. (F) Recapturing the occupation. A basic understanding of the power in reading fiction to regain ordinary life prompts strategies that make it possible to read fiction again. A change is made to more readable books compared with what was read before sick leave so that reading can be fluent. Reading autobiographies or books based on reality strengthens the motivation to read because of the opportunity they offer to make a connection with real life or understand a specific illness. On the other hand, science fiction books motivate reading based on the possibility to move focus to worlds outside a troublesome reality. I couldn’t read at all at first because I was too tired. Then I started to read chick literature and then I could read a book and a half in a week. The other thing with
65
chick literature is that the language doesn’t put up a fight. (B) Bridging the gap to ordinary life. Reading fiction is experienced as a meaningful way to fill time and gain structure in daily life during sick leave. As a way back to ordinary life, it stimulates speeding up the completion of daily activities or duties when there is the prospect of a chance to read, and the good moods that come from reading also give a motivation to carry out other normal activities. When I read I get so absorbed in it that I probably don’t think so much about how it feels but instead I’m there with the book . . . if I have to stop and absolutely don’t want to, there’s a longing to go back to it so that “oh, let’s do this fast so that I can go back to my book”. (E) Other occupations with a fictive content are experienced as not compensating for the inability to read as these forms do not include the intentionality and the deliberate choices connected to reading fiction. I can almost say that reading gives more [than theatre] because I have the possibility to back up a little if I feel like . . . I can go back a little and reread it or read it at my own pace. (H) A feeling of capability This category describes reading fiction as a feeling of being both able and capable. The joy and pleasure connected with regaining the ability to read fiction evoke experiences of capacity concerning both specific abilities and more general skills for coping with life as a whole. Regaining the ability to read is understood as a sign of getting better; it also contributes to happiness over the ability and the fact that the motivation to do things has returned. I took it as a sign of. . .. Hmm . . . like, how good, now I’m starting to be healthy again. My brain is starting to work so much that I can actually sit down and concentrate. (B) The feeling of capability that comes from reading fiction is also based on its power to relieve pain and anxiety. It hurt so much, in my muscles and everywhere and I asked the doctors, like, whether there wasn’t any medicine, so that it would go away . . . but then I noticed that it had that function, both when I listened to novels and when I read . . . it could just take a minute . . . yeah, five minutes . . . and in the beginning I didn’t know that, so I just felt like now I’m calm. (D) A place of refuge This category describes reading fiction as a place of refuge. It is divided into two subcategories, of which
66
L. Mårtensson & C. Andersson
the first describes the need for privacy associated with reading and the second describes the transition from focusing on oneself and the struggle of daily life to focusing on a fictive world. A private zone. Privacy from daily life is experienced as a requirement for being able to read during sick leave. This may be reached by the arrangement of a mental or physical private zone, for some connected with routines or rituals. Making the setting for the occupation comfortable and nice underlines the experience of being in privacy together with the literature as a moment to look forward to, and sometimes as an excuse to spend time with oneself in this private zone. Entering into the private zone with the meaningful activity of reading fiction becomes a deliberate action whose purpose is to show oneself kindness, to have a moment of relaxation, to ease off or as a reward for being able to cope with the daily situation. Having my own moment, like . . . it’s that little room, it’s me and my text. (G) Entering a fictive world. Reading fiction is experienced as an action deliberately taken to move the focus away from demands and problems. This dissociating from oneself into a fictive world is viewed as a possibility to experience other dimensions, instead of being trapped in one’s own thoughts. The fictive world offers new perspectives and access to a bigger world. Entering the fictive world may be a forced action to escape a chaotic reality, but the step between reality and the fictive world may also be less dramatic. I could really feel that I’ll never have a life like that but that I’ve, like, experienced it. Because I get . . . insight into things that are maybe nice in my life and . . . I get to experience something strong that’s happened in someone else’s life . . . and walk beside that person. (D) A life together with others The contents of this category include aspects of feeling an affiliation by reading fiction and companionship with the literature, the fictive characters, and their situations. The category comprises two subcategories. Companionship. Reading fiction during sick leave is experienced in terms of being together in private with a companion or associate. Such a relation with literature may compensate for others who make demands that are too difficult for the existing personal resources. Through their fictiveness, the characters in a book contribute to feelings of sharing the suffering with someone else, and of being consoled and strengthened in the ability to manage one’s own situation.
Taking part in the characters’ experiences or suffering may also allow feelings that have been repressed to come out. Feeling like being a person in the world and finding people . . . who have lived during other times or in other places who have something in common or who think a thought that you’ve thought yourself in some way. (C) I get to read about someone else’s life than my own [laughs]. But also like all other cultures . . . recognizing. That you recognize yourself in others, that you’re not alone. (F) A feeling of affiliation. Despite the fact that it is fictive, the reading involves consideration for the characters and having expectations or being involved in the development of the fictive situations. Knowing that the world is fictive has a value in itself, giving an option to choose how to relate to it or to the characters. Thus, reading is experienced as a filter that makes it possible to identify or distance oneself in the relations associated with the literature. I can dislike somebody in the book very much and I can [laughs] think or feel that another gives me a great deal and like that person. . .. I identify myself with them. . .. I feel like we’re relatives in some way . . . kinship. (H) The feelings of affiliation called up by reading have two directions: one pointing at the desire to stay in a relationship with the literature, not only as an occupation but also to remain in contact with the characters and the context. Another direction is towards relationships in real life, as reading fiction is experienced as something that can be a topic of conversation and that, as such, prepares the way for participation in real contexts. Being a reader also means being involved in social activities during sick leave. Yes, everything else has fallen away. And I questioned then, and I still do, but reading has . . . yes, it’s remained. I’ve kept up with it. I’ve gone to the library every other day, really. (D) A source of power This category describes the ego-strengthening values of reading fiction during sick leave. The fictive experiences described in the literature serve as a source of power by contributing to a stable self-image and being a support in constructing frames of references for life in the future. The category is divided into subcategories representing two different ways of gaining power, both by being a valuable person and by having the strength to move on in life.
Reading fiction during sick leave Gaining value. Different kinds of value are gained by reading fiction. Reading fiction is experienced as an occupation with an inherent status; thus exercising it reinforces the feeling of doing something valuable. Another value in reading fiction appears in the form of a maintained self-image as a reading person, thus promoting the experience of value as a respected person. Yes, it’s been one of the few things that’s been constructive or that’s felt like it’s had some value, because otherwise I would have just laid in front of the TV and that feels meaningless since it’s so easy to do that . . . reading feels like there’s anyway some value in it, that you learn more about something. (A) Gaining strength. Reading fiction without aiming at achievement is valued as a means of enjoyment and a way to reflect on oneself and the present situation. It means gaining insight into what is valuable in life and gives feelings of being refilled and strengthened after completion of the activity that is undertaken. An awareness of the power of literature to influence thoughts and mood means that it is possible to deliberately gain strength by reading. The written language and expressions in the literature are also experienced as a source of enriching feelings and a base for an experience on a deep level. Well, I feel so good when I read so that I feel beautiful and become a happier and nicer person in that way and see the world as a more beautiful place. That’s the way it is. (B) . . . it makes you enjoy the language in a book more or take the time to take a pause where you turn you head away or notice that you’re not concentrating so maybe you don’t read or force yourself. (F) Supporting one’s active self The theme shows an experiential process of reading fiction during sick leave that supports the women’s active self in different ways. In this process the content of the first category, a prospect of ordinary life, describes the motivation and strategies for the recapturing of the occupation. The four other categories are related to reading fiction as having an inherent value while performing the occupation, as a result of the occupation, or as a frame of reference for the sought for ordinary life. Discussion In summary, the five categories describe the experiences of reading fiction among women during a period of sick leave, as a prospect for ordinary life,
67
a feeling of capability, a place of refuge, a life together with others, and a source of power. The five categories of reading fiction represent different experiences of the occupation, both concerning the action itself and the different meanings related to it. A reflection based on the content of the categories and their possible relation to each other indicates that they may be understood as dimensions of reading fiction: most importantly an intentional dimension representing the volitional aspects of the occupation, which may be understood as a prerequisite for reaching all of the other dimensions; a functional dimension that comprises the concrete improvements gained by reading; a mental dimension that has its emphasis on psychological aspects related to the occupation; a relational dimension that is based on the creation of belongingness through reading; and, finally, a personal dimension that represents the ego-strengthening aspects of reading fiction. The process described in the overarching theme, supporting one’s active self, is further strengthened by including the different dimensions. The combination of categories and dimensions makes up a tentative model that may contribute to discussions regarding the power of meaningful occupations. This tentative model is presented in Figure 1 and its content is discussed below. The urge to take up reading fiction again, despite lacking the resources needed to perform it, indicates an intentional dimension of meaning associated with the occupation, as do the deliberate strategies that are used in order to resume the occupation. The results show that it is not necessary to read the usual kind of literature again, nor to read as one normally does; rather, it is reading fiction as an occupation or the role of being a reader that is most important. The intentional dimension of reading fiction also indicates that the occupation must be experienced as meaningful to the degree that you are willing to perform it, despite an awareness of obstacles connected with it. The health benefits of reading fiction may thus originate from the meaningfulness of the occupation, which is in line with theories on occupation (28). The importance of meaningfulness in occupation and its relation to health is furthermore stressed in other studies (29-31). The results presented in the categories describing reading fiction as a means to regain an ordinary life, and the capacity discovered through reading fiction, demonstrate a functional dimension related to the occupation. Using the occupation of reading fiction to fill up time, establish a structure for daily life and compensate for other, more demanding activities may all be regarded as functional aspects on a practical level. Functional aspects on a more personal level are those discovered through reading, such as regained
68
L. Mårtensson & C. Andersson Supporting one′s active self
Intentional dimension A prospect of ordinary life
A desire to fill the gap
Recapturing the occupation
Reading fiction
Bridging the gap to ordinary life
Functional dimension A feeling of capability
Personal dimension A source of power Mental dimension A place of refuge
Relational dimension A life together with others
Figure 1. A tentative model of supporting one’s active self, based on the participants’ experiences of reading fiction during sick leave.
vision, concentration, and coping strategies. The use of reading fiction as a means to speed up the completion of other activities or increase motivation to perform other activities is in line with Frieswijk et al.’s (32) indication that bibliotherapy increases the ability to be active. The functional dimension of reading fiction during sick leave corresponds to the meaning dimension of “doing” (13)” and has a concrete value (12). The results given in the category “a place of refuge” represent a mental dimension of the experiences of reading fiction during sick leave. Being in privacy together with the literature may be understood as something sacred because of the arrangements surrounding the occupation. As such, it may have a symbolic value, which is one of the three value dimensions conceptualized in ValMO (12). The reasons for spending time with the literature in the private zone, e.g. showing oneself kindness, allowing oneself to ease off, or to relax, are in line both with a self-rewarding value as presented in ValMO (12), and the meaning dimension of being as described by Hammell (13). The entering into a fictive world may be related to a transactional perspective, highlighting the holistic character of the relation between a person and the context. In this sense, a person’s re-entering his/her
life world is not an adaptation to the real environment but is built on individual experiences, thoughts, and social meanings (33). The contents of the category “a life together with others” indicate that reading fiction during sick leave also has a relational dimension. The care expressed for the characters and the involvement in the development of fictive situations are in agreement with the Iser’s idea of the reader as co-creative in the interpretation of the literary text (34). Beyond the therapeutic components of bibliotherapy, the compensatory role of reading as concerns relationships, when sufficient resources for real relationships are lacking, enables the experience of belonging during sick leave. Furthermore, the experiences of being part of a context through the reading correspond to the meaning dimension of “belonging”, as well as “becoming”, based on the experiences of being supported in giving a framework to the healthy life to come via reading (13). In the form of the companionship of a fictive friend or a supporting group, as suggested by Cohen (7), reading fiction also has relational values for real life among the participating women. Visiting libraries and book clubs is further proof of the power of reading as a link to the performance of other activities or occupations.
Reading fiction during sick leave The women’s experiences of being strengthened by reading fiction during sick leave offer a personal dimension of the occupation. The results, in the form of improved self-image and evoking the hope of being normal again, are strongly associated with the meaning dimension of “becoming” (13)”. Because of the women’s lifelong interest in reading fiction, recapturing this occupation means recapturing a habit of daily life. This must be seen as a positive aspect of the process of change, as regaining habits is described as contributing to an enhanced occupational identity (35). According to Hasselkus (36), this development of the self could be expressed either as how occupations help to express the inner, present self or help to define the possible self, both of which are present in the women’s stories of their reading experiences. In a transactional view, it is through the dynamic relationship between the person and the physical, social, or symbolic environment that habits are formed. These configurations of habits become the basis of action, occupation, and responses to changes (33). The results also show associations to Fisher’s (37) suggestion of an occupation-related taxonomy. Based on this, the women’s experiences of fiction as a determinant for being engaged and participating in daily life may be regarded as occupation based and occupation focused. To gain this new understanding, the authors used an occupation-centred approach in both data collection and analysis (37). Strengths and limitations The study has both strengths and limitations. The experiences presented in the five categories are based on data collected from a small, limited group of women that shows homogeneity concerning reading fiction as a lifelong interest, reading fiction during a period of sick leave, and an interest in sharing their experiences. Thus, the transferability of the results must be regarded as limited, due to the small sample size. However, the purpose of the study was not to generalize but rather to explore reading fiction based on an occupational perspective, and an advantage of a small sample size is that it permits in-depth analysis (38). In contrast to the homogeneity concerning reading habits, the group of women was heterogenic with regard to age, professional background, reason for and endurance of sick leave, as well as reading frequency. This heterogeneity contributed to a variation of experiences and richness of content, which appears in the results in the form of the broadness of the dimensions related to the five categories. Furthermore, the answers given in the interviews gave the impression of personal expressions of reality as it was experienced, thus securing the reasonability of the
69
results. Based on the participants’ lifelong interest in reading fiction and the richness and variation exhibited, the appropriateness of the results may be judged as sufficient. With regard to credibility, the continuous discussion between the two authors in the analysis of the interpretation of the embedded meaning of the data is judged to enhance the quality of the results, as does the change between contextualization and de-contextualization during the interpretation step in the analysis. The pre-understanding of both authors as experienced occupational therapists may have influenced the research process. However, this background may be judged as a resource in capturing the different experiences of reading fiction that was sought in this study. A central element in the occupational therapy process is to gain and understand the underlying meaning of occupation and the motives for performing it (39). Such experiences may have contributed to the appropriateness of the interpretations made. Conclusions and implications In conclusion, this research describes the experienced relevance of a self-initiated, meaningful occupation for the ability to participate in daily-life occupations. The experiences described are related to both an external reality and an internal subjective context. On the external level, the reading of fiction contributes to regaining capacity and to re-creating structure in daily life. In the internal context, reading fiction contributes to enabling new ways of development and the feeling of being capable and can constitute a person’s own room for recovery. The health-related dimensions of reading fiction presented in the results make clear that reading fiction should be regarded as a significant occupation comparable with other, more highlighted ones. The tentative model of supporting one’s active self may be helpful in clarifying the mechanisms of this process. Understood in this way, it can be argued that the results add to the knowledge base in occupational therapy that focuses on how meaningful occupations connect to occupational life trajectories (40) and how engagement in valued activities enhances well-being (41). In a clinical setting, such a focus could help clients gain a better understanding of how participation in meaningful occupations contributes to the pathways of recovery. Research on such effects is warranted. The study should be repeated based on another self-initiated occupation to further explore the different dimensions associated with reading fiction during sick leave that were found in this study. This would also be a way to validate the tentative model proposed in the discussion section. Further, to proceed in the
70
L. Mårtensson & C. Andersson
analytic reasoning about this occupation on a more theoretical level, it is also necessary to explore reading fiction among men on sick leave and in healthy persons of both sexes.
Acknowledgement The authors would like to express their gratitude to the funder of this study, Anna Ahrenberg’s Foundation for scientific and other purposes. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Hynes A, Hynes-Berry M. Biblio-poetry therapy: the interactive process. A handbook. Westview Press; Boulder: 1986. 2. Den Boer PC, Wiersma D, Van den Bosch RJ. Why is self-help neglected in the treatment of emotional disorders? A metaanalysis. Psychol Med 2004;34:959–71. 3. Jorm AF, Griffiths KM, Christensen H, Rodgers B. Effectiveness of complementary and self-help treatments for depression. Med J Aust 2002;176:S84–95. 4. Newman MG, Erickson T, Prseworski A. Dzus, E. Self-help and minimal-contact therapies for anxiety disorders: Is human contact necessary? J Clin Psychol 2003;59:251–74. 5. Russell DH, Shrodes C. Contributions of research in bibliotherapy to the language arts program. Sch Rev. 1950;50:335. 6. Fanner D, Urquhart C. Bibliotherapy for mental health users, Part 1: a systematic review. Health Info Libr J 2008; 25:237–52. 7. Cohen LJ. Bibliotherapy: the experience of therapeutic reading from the perspective of the adult reader. New York University; New York: 1992. 8. Christiansen CH, Townsend EA. editors. Introduction to occupation: the art and science of living. 2nd edition. Pearson Education; Upper Saddle River: 2010. 9. Townsend EA, Polatajko HJ. Enabling occupation II: advancing an occupational therapy vision for health, well-being & justice through occupation. Ottawa: CAOT Publications ACE; 2007. 10. Cohen LJ. Phenomenology of therapeutic reading with implications for research and practice of bibliotherapy. Arts Psychother 1994;1:37–44. 11. Mårtensson L, Hensing G. Experiences of factors contributing to women’s ability to make informed decisions about the process of rehabilitation and return to work: A focus group study. Work 2010;43:237–48. 12. Persson D, Erlandsson L-K, Eklund M, Ivarsson S. Value dimensions, meaning and complexity in human occupation: A tentative structure for analysis. Scand J Occup Ther 2001;8:7–18. 13. Hammell K. Dimensions of meaning in the occupations of daily life. Can J Occup Ther 2004;71:296–305. 14. Wilcock AA. Occupation and health: Are they one and the same? J Occup Sci 2007;14:3–8. 15. Kaltenthaler E, Parry G, Beverley C. Computerized cognitive behavior therapy: A systematic review. Behav Cogn Psychother 2004;32:31–55. 16. Harvey P. Bibliotherapy use by welfare teams in secondary colleges. Aust J Teach Educ 2010;35:29–39.
17. Garland J. Adaptation skills in the elderly, their supporters and carers. Br J Med Psychol 1985;58:267–74. 18. McKinney F. Explorations in bibliotherapy: Personal involvement in short stories and cases. Psychother Theory Res Pract 1975;12:110–17. 19. Stephenson SM, Smith YJ, Gibson M, Watson V. Traditional weaving as an occupation of Karen refugee women. J Occup Sci 2013;20:224–35. 20. National Endowment for the Arts. Reading on the rise: a new chapter in American literacy. National Endowment for the Arts; Washington, DC: 2009. 21. Casini A, Godin I, Clays E, Kittel F. Gender difference in sickness absence from work: A multiple mediation analysis of psychosocial factors. Eur J Public Health 2013;23:635–42. 22. Hensing G, Brage S, Nygård J, Sandanger I, Tellnes G. Sickness absence with psychiatric disorders: An increased risk for marginalisation among men? Soc Psychiatry Psychiatr Epidemiol 2000;35:335–40. 23. Nystuen P, Hagen K, Herrin J. Mental health problems as a cause of long-term sick leave in the Norwegian workforce. Scand J Public Health 2001;29:175–82. 24. Morse JM. Strategies for sampling. In Morse JM, editor. Qualitative nursing research: a contemporary dialogue. Sage Publications; Newbury Park, CA: 1991. pp 127–34. 25. Strauss A, Corbin J. Basics of qualitative research: techniques and procedures for developing Grounded Theory. 2nd edition. Sage Publications; Newbury Park, CA: 1998. 26. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24:105–12. 27. Fridlund B, Hildingh C. Health and qualitative analysis methods. In Fridlund B, Hilding C, editors. Qualitative research methods in the service of health. Studentlitteratur; Lund: 2000. pp 13–25. 28. Reed K, Smythe L, Hocking C. The meaning of occupation: A hermeneutic (re)view of historical understandings. J Occup Sci 2013;20:253–61. 29. Hvalsøe B, Josephsson S. Characteristics of meaningful occupations from the perspective of mentally ill people. Scand J Occup Ther 2003;10:61–71. 30. Leufstadius C, Erlandsson LK, Björkman T, Eklund M. Meaningfulness in daily occupations among individuals with persistent mental illness. J Occup Sci 2008;15:27–35. 31. Andersson C, Eklund M, Sund V, Thundal K-L, Spak F. Women’s patterns of everyday occupations and alcohol consumption. Scand J Occup Ther 2012;19:225–38. 32. Frieswijk N, Stevering N, Buunk BP, Slaets JPJ. The effectiveness of a bibliotherapy in increasing the self-management ability of slightly to moderately frail older people. Patient Educ Couns 2006;61:219–27. 33. Cutchin MP, Dickie VA. Transactionalism: occupational science and the pragmatic attitude. In Whiteford GE, Hocking C, editors. Occupational science: society, inclusion, participation. Blackwell; Oxford: 2012. pp 23–37. 34. Iser W. The act of reading; a theory of aesthetic response. Baltimore: John Hopkins University Press, 1991. 35. Kielhofner G. Dimensions of doing. In Kielhofner G, editor. Model of human occupation: theory and application. Lippincott Willams & Wilkins, Baltimore; 2008;pp 101–9. 36. Hasselkus BR. The meaning of everyday occupation. Slack; Thorofare, NJ: 2011. 37. Fisher AG. Occupation-centred, occupation-based, occupation-focused: Same, same or different? Scand J Occup Ther 2013;20:162–73. 38. Sandelowski M. Sample size in qualitative research. Res Nurs Health 1995;18:179–83.
Reading fiction during sick leave 39. Craik J, Davis J, Polatajko HJ. Introducing the Canadian Practice Process Framework (CPFF): Amplifying the context. In Townsend E, Polatajko HL, editors. Enabling occupation II: advancing an occupational therapy vision for health, wellbeing, & justice through occupation. CAOT; Ottawa: 2007. pp 247–72.
71
40. Ikiugu MN. Meaningfulness of occupations as an occupationallife-trajectory attractor. J Occup Sci 2005;12:102–9. 41. Lal S, Ungar ML, Leggo C, Malla A, Frankish J, Suto MJ. Well-being and engagement in valued activities: Experiences of young people with psychosis. OTJR (Thorofare N J) 2013; 33:190–7.
Copyright of Scandinavian Journal of Occupational Therapy is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ORIGINAL ARTICLE
Reading fiction during sick leave, a multidimensional occupation
LENA MÅRTENSSON & CHRISTINA ANDERSSON Institute of Neuroscience and Physiology/Occupational Therapy, Sahlgrenska Academy, Göteborg University, Göteborg, Sweden
Abstract Background: In bibliotherapy, the therapeutic gains of reading fiction are ascribed to the literature. Viewing reading fiction as an occupation may give other explanations of its therapeutic function. Aim: The aim of this qualitative study was to explore the experiences of reading fiction among women during a period of sick leave. Material and methods: A qualitative approach was applied. Eight women who had been reading fiction during sick leave were interviewed. Results: An overarching theme: Supporting one’s active self, comprised five categories of experiences: a prospect of ordinary life, a place of refuge, a life together with others, a source of power, and as supporting an active life. Conclusion and significance: Based on the categories, reading fiction is seen to comprise intentional, functional, mental, relational, and personal dimensions. A tentative model of supporting one’s active self is proposed, which may be helpful in clarifying the mechanisms of the process of change. The health-related dimensions of reading fiction suggest that reading fiction should be regarded as a significant occupation comparable with other, more highlighted ones. Understood in this way, it is argued that the results add to the knowledge base in occupational therapy focusing on how meaningful occupations connect to occupational life trajectories.
Key words: qualitative research, occupational dimensions, Bibliotherapy
Introduction The use of literature to improve people’s mental health goes under the name of bibliotherapy (1) in the treatment of persons with emotional disorders such as depression and anxiety (2-4). In this therapeutic form, it is considered that the gains of reading fiction are ascribed to the interaction between the reader and the literature (5). A systematic literature review (6) showed that bibliotherapy is cost effective as support in treating different forms of psychological ill health. However, there is no evidence for how the use of literature contributes to increasing mental health. A suggested explanation for the therapeutic power of reading is that it has the function of a fictive friend or support group and that it gives the possibility to become absorbed and to escape from problems (7).
Viewing reading fiction as an occupation may give other explanations of its therapeutic function, as the meaning component of occupations is considered to be an important factor when discussing the relationship between occupation and health (8,9). If fiction reading is a habitual occupation before the onset of illness, it may validate unaffected abilities and capacities during times of illness and thereby contribute to a view of self as a healthy and competent person. Being confirmed and recognizing oneself, which are important aspects in therapeutic reading (10), have been shown to be significant forces in rehabilitation in, for example, long-term pain conditions (11). Based on the structure of the Value and Meaning of Occupations Model (ValMO) (12), there are potential values inherent in any single occupation. Thus, the occupation of reading fiction may include concrete, symbolic, and self-rewarding values that may explain
Correspondence: Lena Mårtensson, PhD Reg OT, Institute of Neuroscience and Physiology/Occupational Therapy, PO Box 455, SE 405 30 Göteborg, Sweden. Tel: +46 703 336948. Fax: +46 31 786 5723. E-mail: [email protected] (Received 15 April 2014; accepted 13 August 2014) ISSN 1103-8128 print/ISSN 1651-2014 online 2015 Informa Healthcare DOI: 10.3109/11038128.2014.955877
Reading fiction during sick leave the efficacy of this occupation in times of ill health. The dimensions related to occupation comprising meaning in the form of doing, being, becoming, and belonging (13,14) may also be applicable to the occupation of reading fiction. Besides the possibility to have something relevant to do, reading fiction may be seen as an opportunity to achieve a state of being by becoming absorbed in a fictive world. It may also lead to gaining the social role as a reader, with its relevance for belonging in contexts where reading fiction is a key for inclusion. It seems important to explore the reasons for reading fiction as an occupation, and its benefits for persons with health problems, based on an occupational perspective, as there is in principle no research based on this perspective. A search in the Scopus database with the search combination “occupation” AND “reading fiction” OR “bibliotherapy” in the title, abstract or key words resulted in six titles published between 1975 and 2014, of which four were written in English (15–18). Of those, one literature review compared a cognitive intervention with different kinds of therapies, e.g. bibliotherapy and occupational therapy (15). In the other ones the concept occupation was not mentioned at all, or was not applicable to the occupation reading fiction. Expanding the focus on reading from being a therapeutic tool to investigating how engagement in reading is experienced as being linked to different aspects of everyday life could contribute to further explaining the presupposed association between occupation and health (14,19). The aim of this study was to explore the experiences of reading fiction among women during a period of sick leave. The reasons for focusing on women’s therapeutic reading are several. Women read more than men (20). Furthermore, women are more absent from work due to illness than men (21) and mental illness, for which reading fiction is most often used as therapy, is a more common reason for sick leave among women than men (22,23).
Material and methods Design and setting The study had an exploratory and qualitative design, as the aim was to gain and describe new knowledge. A hermeneutic approach was applied to capture the subjective experiences of reading fiction during sick leave. The study was carried out in a town with > 500 000 inhabitants, in the south-west of Sweden, and the research plan in its entirety was approved by the Regional Ethical Review Board in Gothenburg (Dnr 249-11). Both authors are registered occupational
63
therapists without any experiences of using bibliotherapy as a tool in practice. Participants The participants were recruited by purposeful sampling (24). Flyers with brief information about the study were strategically placed in bookshops, libraries, educational associations, health activity centres, etc. The flyers included a web address for a homepage with detailed information about the study and participation. There was a link on the homepage for visitors who were interested in participating to contact the researchers. Criteria for participation were: . . . . .
Woman of working age who was or recently had been on sick leave for at least three months. A physical or mental condition as the reason for sick leave. Ability to read hard-copy books or listen to audio books. Reading at least one book a month during the sick leave. Ability to understand and speak Swedish without the assistance of an interpreter. The exclusion criterion was:
.
A sick leave period concluded more than 12 months before recruitment.
Ten women showed interest in participating. They were contacted by telephone to give verbal information about the study’s aim and the interview method, as well as to ensure that participation was voluntary and that no unauthorized person would gain access to the research material. Two of the women that showed interest were excluded as they did not fulfil the criterion of ongoing or recent sick leave. Thus, the study included eight women of various ages. For all eight participants, reading fiction was a lifelong interest and, for all of them, there was a time early in the sick leave period when reading was not possible because of the demands it places and the fact that their focus was on simply surviving or living from day to day. The authors did not have any kind of relationship with the participants. The demographics of the participants are given in Table I. Data collection The interviews were carried out using an interview guide that included different aspects of reading fiction during a period of sick leave. The open-ended interview questions served as a general basis for reaching more specific and deeper questions on different factors.
64
L. Mårtensson & C. Andersson
Table I. Demographics of the eight participants (A–H).
Profession
Reason for sick-leave
Sick leave duration (months)
Reading frequency during sick leave (books per month)
Participant
Age (year)
A
34
Student
Cancer
6
4
B
39
Journalist
Post-traumatic stress
7
4
C
40
Librarian
Cancer
4
4
D
42
Teacher
Burn-out depression
7
6
E
44
Social worker
Burn-out depression
4
4
F
26
Personal assistant
Psychosis
16
2
G
52
Self employed
Burn-out depression
36
1
H
67
Physiotherapist
Cancer
9
1
The interview guide included questions like: How would you describe your interest in reading fiction? As an occupation, how important is reading fiction for you? What are your experiences of reading during your period of sick leave? Is it different from your ordinary reading? Do you connect reading fiction during sick leave with any kind of value? Does reading fiction influence you in any way during sick leave, physically or mentally, in performing activities and in social participation? Based on inspiration from Grounded Theory (25), a brief analysis was carried out after each interview to gain an overall understanding of the experiences and to develop new questions in the subsequent interviews. Each participant was interviewed once. The interviews were carried out in places chosen by the participants. Four of them took place at parlour rooms at a university, three in the participants’ homes, and one on Skype. It was attempted in the interviews to maintain a balance of power, concerning preferential right of interpretation and meaning of concepts and words from both parts. This form of reflexivity was promoted by performing the interviews in a relaxed way, so that it was more like a conversation than a formal interview, and by letting the interviewees react to perceived meanings. The interviews, which were digitally recorded, lasted from 60 to 90 minutes. Analysis Content analysis as described by Graneheim & Lundman (26) was used to reach qualitative descriptions of the women’s experiences of reading fiction during sick leave. The analysis process started with a word-by-word transcription (in Swedish) of each interview after its completion. All of the interviews were read through several times to obtain a sense of the whole. The texts that concerned the experiences of reading fiction were then extracted and brought together. This
text constituted the unit of analysis. The next step was to divide the text into meaning units that were condensed. The condensed meaning units were then abstracted and coded on the basis of their inherent meaning (26). In concrete terms, this was done by continuous discussion between the authors regarding possible inherent meanings and by contextualization of the meaning units in the individual interviews and in the data as a whole (27). The new questions formulated, based on the brief analysis after each interview implied a gradually deeper understanding of the meaning of the phenomenon studied. The next step involved comparing the codes based on differences and similarities in order to distinguish patterns of experiences (26). Reflexivity was considered both by maintaining awareness of the professional preunderstanding and by looking for multiple interpretations of the experiences described. The patterns that emerged were arranged into 12 tentative categories, which constituted the content. These were reflected on and discussed by the authors. The discussion between the authors resulted in agreement on the structural patterns of the tentative categories; based on their similarities and differences, five qualitative categories representing different aspects of meaning finally emerged. The categories were compared with the empirical Swedish raw data, i.e. the transcribed interviews, in order to test the trustworthiness of the emerging categories. The final step of the analysis included a discussion about the underlying meaning, the latent content of the categories (26). This resulted in a theme representing the experience of reading fiction during sick leave as supporting the women’s active selves. Both authors were involved in all parts of the analysis, and there was continuous discussion between the authors at every step of the process concerning the interpretations and possible meanings, based on reflection on previous knowledge – professional knowledge and that acquired by experience.
Reading fiction during sick leave Results Five categories emerged, representing different experiences of the occupation of reading fiction during sick leave. Significant citations are given for each category, followed by a letter in brackets (A–H), indicating the participant being quoted. The categories are termed: a prospect of ordinary life, a feeling of capability, a place of refuge, a life together with others, and a source of power. An overarching theme, “supporting one’s active self”, covered the underlying meaning of all the categories as well as the relations between the categories. A prospect of ordinary life This category describes reading fiction as a means to regain an ordinary life, as life is not experienced as it used to be without reading fiction. The category comprises three subcategories. Filling the gap. Due to the meaning associated with reading fiction, the involuntary “reading break” during the first part of the sick leave means that a substantial part of life is missing. Reading fiction is deliberately chosen to fill this gap in daily life. Compared with other occupations, reading fiction is experienced as being associated with small demands and, as such, as a valuable, meaningful, and harmless compensation for other, unrealizable, occupations. The urge to recapture the ability to read fiction is also based on a desire to fulfil the ordinary self-image as a reader. Reading has been extremely important not to be trapped in the little igloo you’re in when you’re on sick leave . . . you’re a little screened from reality in a way . . . you’re not in the loop . . . you look through the window, and it’s there that life is going on, but when I read I get outside that and simply get another dimension of the world. (F) Recapturing the occupation. A basic understanding of the power in reading fiction to regain ordinary life prompts strategies that make it possible to read fiction again. A change is made to more readable books compared with what was read before sick leave so that reading can be fluent. Reading autobiographies or books based on reality strengthens the motivation to read because of the opportunity they offer to make a connection with real life or understand a specific illness. On the other hand, science fiction books motivate reading based on the possibility to move focus to worlds outside a troublesome reality. I couldn’t read at all at first because I was too tired. Then I started to read chick literature and then I could read a book and a half in a week. The other thing with
65
chick literature is that the language doesn’t put up a fight. (B) Bridging the gap to ordinary life. Reading fiction is experienced as a meaningful way to fill time and gain structure in daily life during sick leave. As a way back to ordinary life, it stimulates speeding up the completion of daily activities or duties when there is the prospect of a chance to read, and the good moods that come from reading also give a motivation to carry out other normal activities. When I read I get so absorbed in it that I probably don’t think so much about how it feels but instead I’m there with the book . . . if I have to stop and absolutely don’t want to, there’s a longing to go back to it so that “oh, let’s do this fast so that I can go back to my book”. (E) Other occupations with a fictive content are experienced as not compensating for the inability to read as these forms do not include the intentionality and the deliberate choices connected to reading fiction. I can almost say that reading gives more [than theatre] because I have the possibility to back up a little if I feel like . . . I can go back a little and reread it or read it at my own pace. (H) A feeling of capability This category describes reading fiction as a feeling of being both able and capable. The joy and pleasure connected with regaining the ability to read fiction evoke experiences of capacity concerning both specific abilities and more general skills for coping with life as a whole. Regaining the ability to read is understood as a sign of getting better; it also contributes to happiness over the ability and the fact that the motivation to do things has returned. I took it as a sign of. . .. Hmm . . . like, how good, now I’m starting to be healthy again. My brain is starting to work so much that I can actually sit down and concentrate. (B) The feeling of capability that comes from reading fiction is also based on its power to relieve pain and anxiety. It hurt so much, in my muscles and everywhere and I asked the doctors, like, whether there wasn’t any medicine, so that it would go away . . . but then I noticed that it had that function, both when I listened to novels and when I read . . . it could just take a minute . . . yeah, five minutes . . . and in the beginning I didn’t know that, so I just felt like now I’m calm. (D) A place of refuge This category describes reading fiction as a place of refuge. It is divided into two subcategories, of which
66
L. Mårtensson & C. Andersson
the first describes the need for privacy associated with reading and the second describes the transition from focusing on oneself and the struggle of daily life to focusing on a fictive world. A private zone. Privacy from daily life is experienced as a requirement for being able to read during sick leave. This may be reached by the arrangement of a mental or physical private zone, for some connected with routines or rituals. Making the setting for the occupation comfortable and nice underlines the experience of being in privacy together with the literature as a moment to look forward to, and sometimes as an excuse to spend time with oneself in this private zone. Entering into the private zone with the meaningful activity of reading fiction becomes a deliberate action whose purpose is to show oneself kindness, to have a moment of relaxation, to ease off or as a reward for being able to cope with the daily situation. Having my own moment, like . . . it’s that little room, it’s me and my text. (G) Entering a fictive world. Reading fiction is experienced as an action deliberately taken to move the focus away from demands and problems. This dissociating from oneself into a fictive world is viewed as a possibility to experience other dimensions, instead of being trapped in one’s own thoughts. The fictive world offers new perspectives and access to a bigger world. Entering the fictive world may be a forced action to escape a chaotic reality, but the step between reality and the fictive world may also be less dramatic. I could really feel that I’ll never have a life like that but that I’ve, like, experienced it. Because I get . . . insight into things that are maybe nice in my life and . . . I get to experience something strong that’s happened in someone else’s life . . . and walk beside that person. (D) A life together with others The contents of this category include aspects of feeling an affiliation by reading fiction and companionship with the literature, the fictive characters, and their situations. The category comprises two subcategories. Companionship. Reading fiction during sick leave is experienced in terms of being together in private with a companion or associate. Such a relation with literature may compensate for others who make demands that are too difficult for the existing personal resources. Through their fictiveness, the characters in a book contribute to feelings of sharing the suffering with someone else, and of being consoled and strengthened in the ability to manage one’s own situation.
Taking part in the characters’ experiences or suffering may also allow feelings that have been repressed to come out. Feeling like being a person in the world and finding people . . . who have lived during other times or in other places who have something in common or who think a thought that you’ve thought yourself in some way. (C) I get to read about someone else’s life than my own [laughs]. But also like all other cultures . . . recognizing. That you recognize yourself in others, that you’re not alone. (F) A feeling of affiliation. Despite the fact that it is fictive, the reading involves consideration for the characters and having expectations or being involved in the development of the fictive situations. Knowing that the world is fictive has a value in itself, giving an option to choose how to relate to it or to the characters. Thus, reading is experienced as a filter that makes it possible to identify or distance oneself in the relations associated with the literature. I can dislike somebody in the book very much and I can [laughs] think or feel that another gives me a great deal and like that person. . .. I identify myself with them. . .. I feel like we’re relatives in some way . . . kinship. (H) The feelings of affiliation called up by reading have two directions: one pointing at the desire to stay in a relationship with the literature, not only as an occupation but also to remain in contact with the characters and the context. Another direction is towards relationships in real life, as reading fiction is experienced as something that can be a topic of conversation and that, as such, prepares the way for participation in real contexts. Being a reader also means being involved in social activities during sick leave. Yes, everything else has fallen away. And I questioned then, and I still do, but reading has . . . yes, it’s remained. I’ve kept up with it. I’ve gone to the library every other day, really. (D) A source of power This category describes the ego-strengthening values of reading fiction during sick leave. The fictive experiences described in the literature serve as a source of power by contributing to a stable self-image and being a support in constructing frames of references for life in the future. The category is divided into subcategories representing two different ways of gaining power, both by being a valuable person and by having the strength to move on in life.
Reading fiction during sick leave Gaining value. Different kinds of value are gained by reading fiction. Reading fiction is experienced as an occupation with an inherent status; thus exercising it reinforces the feeling of doing something valuable. Another value in reading fiction appears in the form of a maintained self-image as a reading person, thus promoting the experience of value as a respected person. Yes, it’s been one of the few things that’s been constructive or that’s felt like it’s had some value, because otherwise I would have just laid in front of the TV and that feels meaningless since it’s so easy to do that . . . reading feels like there’s anyway some value in it, that you learn more about something. (A) Gaining strength. Reading fiction without aiming at achievement is valued as a means of enjoyment and a way to reflect on oneself and the present situation. It means gaining insight into what is valuable in life and gives feelings of being refilled and strengthened after completion of the activity that is undertaken. An awareness of the power of literature to influence thoughts and mood means that it is possible to deliberately gain strength by reading. The written language and expressions in the literature are also experienced as a source of enriching feelings and a base for an experience on a deep level. Well, I feel so good when I read so that I feel beautiful and become a happier and nicer person in that way and see the world as a more beautiful place. That’s the way it is. (B) . . . it makes you enjoy the language in a book more or take the time to take a pause where you turn you head away or notice that you’re not concentrating so maybe you don’t read or force yourself. (F) Supporting one’s active self The theme shows an experiential process of reading fiction during sick leave that supports the women’s active self in different ways. In this process the content of the first category, a prospect of ordinary life, describes the motivation and strategies for the recapturing of the occupation. The four other categories are related to reading fiction as having an inherent value while performing the occupation, as a result of the occupation, or as a frame of reference for the sought for ordinary life. Discussion In summary, the five categories describe the experiences of reading fiction among women during a period of sick leave, as a prospect for ordinary life,
67
a feeling of capability, a place of refuge, a life together with others, and a source of power. The five categories of reading fiction represent different experiences of the occupation, both concerning the action itself and the different meanings related to it. A reflection based on the content of the categories and their possible relation to each other indicates that they may be understood as dimensions of reading fiction: most importantly an intentional dimension representing the volitional aspects of the occupation, which may be understood as a prerequisite for reaching all of the other dimensions; a functional dimension that comprises the concrete improvements gained by reading; a mental dimension that has its emphasis on psychological aspects related to the occupation; a relational dimension that is based on the creation of belongingness through reading; and, finally, a personal dimension that represents the ego-strengthening aspects of reading fiction. The process described in the overarching theme, supporting one’s active self, is further strengthened by including the different dimensions. The combination of categories and dimensions makes up a tentative model that may contribute to discussions regarding the power of meaningful occupations. This tentative model is presented in Figure 1 and its content is discussed below. The urge to take up reading fiction again, despite lacking the resources needed to perform it, indicates an intentional dimension of meaning associated with the occupation, as do the deliberate strategies that are used in order to resume the occupation. The results show that it is not necessary to read the usual kind of literature again, nor to read as one normally does; rather, it is reading fiction as an occupation or the role of being a reader that is most important. The intentional dimension of reading fiction also indicates that the occupation must be experienced as meaningful to the degree that you are willing to perform it, despite an awareness of obstacles connected with it. The health benefits of reading fiction may thus originate from the meaningfulness of the occupation, which is in line with theories on occupation (28). The importance of meaningfulness in occupation and its relation to health is furthermore stressed in other studies (29-31). The results presented in the categories describing reading fiction as a means to regain an ordinary life, and the capacity discovered through reading fiction, demonstrate a functional dimension related to the occupation. Using the occupation of reading fiction to fill up time, establish a structure for daily life and compensate for other, more demanding activities may all be regarded as functional aspects on a practical level. Functional aspects on a more personal level are those discovered through reading, such as regained
68
L. Mårtensson & C. Andersson Supporting one′s active self
Intentional dimension A prospect of ordinary life
A desire to fill the gap
Recapturing the occupation
Reading fiction
Bridging the gap to ordinary life
Functional dimension A feeling of capability
Personal dimension A source of power Mental dimension A place of refuge
Relational dimension A life together with others
Figure 1. A tentative model of supporting one’s active self, based on the participants’ experiences of reading fiction during sick leave.
vision, concentration, and coping strategies. The use of reading fiction as a means to speed up the completion of other activities or increase motivation to perform other activities is in line with Frieswijk et al.’s (32) indication that bibliotherapy increases the ability to be active. The functional dimension of reading fiction during sick leave corresponds to the meaning dimension of “doing” (13)” and has a concrete value (12). The results given in the category “a place of refuge” represent a mental dimension of the experiences of reading fiction during sick leave. Being in privacy together with the literature may be understood as something sacred because of the arrangements surrounding the occupation. As such, it may have a symbolic value, which is one of the three value dimensions conceptualized in ValMO (12). The reasons for spending time with the literature in the private zone, e.g. showing oneself kindness, allowing oneself to ease off, or to relax, are in line both with a self-rewarding value as presented in ValMO (12), and the meaning dimension of being as described by Hammell (13). The entering into a fictive world may be related to a transactional perspective, highlighting the holistic character of the relation between a person and the context. In this sense, a person’s re-entering his/her
life world is not an adaptation to the real environment but is built on individual experiences, thoughts, and social meanings (33). The contents of the category “a life together with others” indicate that reading fiction during sick leave also has a relational dimension. The care expressed for the characters and the involvement in the development of fictive situations are in agreement with the Iser’s idea of the reader as co-creative in the interpretation of the literary text (34). Beyond the therapeutic components of bibliotherapy, the compensatory role of reading as concerns relationships, when sufficient resources for real relationships are lacking, enables the experience of belonging during sick leave. Furthermore, the experiences of being part of a context through the reading correspond to the meaning dimension of “belonging”, as well as “becoming”, based on the experiences of being supported in giving a framework to the healthy life to come via reading (13). In the form of the companionship of a fictive friend or a supporting group, as suggested by Cohen (7), reading fiction also has relational values for real life among the participating women. Visiting libraries and book clubs is further proof of the power of reading as a link to the performance of other activities or occupations.
Reading fiction during sick leave The women’s experiences of being strengthened by reading fiction during sick leave offer a personal dimension of the occupation. The results, in the form of improved self-image and evoking the hope of being normal again, are strongly associated with the meaning dimension of “becoming” (13)”. Because of the women’s lifelong interest in reading fiction, recapturing this occupation means recapturing a habit of daily life. This must be seen as a positive aspect of the process of change, as regaining habits is described as contributing to an enhanced occupational identity (35). According to Hasselkus (36), this development of the self could be expressed either as how occupations help to express the inner, present self or help to define the possible self, both of which are present in the women’s stories of their reading experiences. In a transactional view, it is through the dynamic relationship between the person and the physical, social, or symbolic environment that habits are formed. These configurations of habits become the basis of action, occupation, and responses to changes (33). The results also show associations to Fisher’s (37) suggestion of an occupation-related taxonomy. Based on this, the women’s experiences of fiction as a determinant for being engaged and participating in daily life may be regarded as occupation based and occupation focused. To gain this new understanding, the authors used an occupation-centred approach in both data collection and analysis (37). Strengths and limitations The study has both strengths and limitations. The experiences presented in the five categories are based on data collected from a small, limited group of women that shows homogeneity concerning reading fiction as a lifelong interest, reading fiction during a period of sick leave, and an interest in sharing their experiences. Thus, the transferability of the results must be regarded as limited, due to the small sample size. However, the purpose of the study was not to generalize but rather to explore reading fiction based on an occupational perspective, and an advantage of a small sample size is that it permits in-depth analysis (38). In contrast to the homogeneity concerning reading habits, the group of women was heterogenic with regard to age, professional background, reason for and endurance of sick leave, as well as reading frequency. This heterogeneity contributed to a variation of experiences and richness of content, which appears in the results in the form of the broadness of the dimensions related to the five categories. Furthermore, the answers given in the interviews gave the impression of personal expressions of reality as it was experienced, thus securing the reasonability of the
69
results. Based on the participants’ lifelong interest in reading fiction and the richness and variation exhibited, the appropriateness of the results may be judged as sufficient. With regard to credibility, the continuous discussion between the two authors in the analysis of the interpretation of the embedded meaning of the data is judged to enhance the quality of the results, as does the change between contextualization and de-contextualization during the interpretation step in the analysis. The pre-understanding of both authors as experienced occupational therapists may have influenced the research process. However, this background may be judged as a resource in capturing the different experiences of reading fiction that was sought in this study. A central element in the occupational therapy process is to gain and understand the underlying meaning of occupation and the motives for performing it (39). Such experiences may have contributed to the appropriateness of the interpretations made. Conclusions and implications In conclusion, this research describes the experienced relevance of a self-initiated, meaningful occupation for the ability to participate in daily-life occupations. The experiences described are related to both an external reality and an internal subjective context. On the external level, the reading of fiction contributes to regaining capacity and to re-creating structure in daily life. In the internal context, reading fiction contributes to enabling new ways of development and the feeling of being capable and can constitute a person’s own room for recovery. The health-related dimensions of reading fiction presented in the results make clear that reading fiction should be regarded as a significant occupation comparable with other, more highlighted ones. The tentative model of supporting one’s active self may be helpful in clarifying the mechanisms of this process. Understood in this way, it can be argued that the results add to the knowledge base in occupational therapy that focuses on how meaningful occupations connect to occupational life trajectories (40) and how engagement in valued activities enhances well-being (41). In a clinical setting, such a focus could help clients gain a better understanding of how participation in meaningful occupations contributes to the pathways of recovery. Research on such effects is warranted. The study should be repeated based on another self-initiated occupation to further explore the different dimensions associated with reading fiction during sick leave that were found in this study. This would also be a way to validate the tentative model proposed in the discussion section. Further, to proceed in the
70
L. Mårtensson & C. Andersson
analytic reasoning about this occupation on a more theoretical level, it is also necessary to explore reading fiction among men on sick leave and in healthy persons of both sexes.
Acknowledgement The authors would like to express their gratitude to the funder of this study, Anna Ahrenberg’s Foundation for scientific and other purposes. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Hynes A, Hynes-Berry M. Biblio-poetry therapy: the interactive process. A handbook. Westview Press; Boulder: 1986. 2. Den Boer PC, Wiersma D, Van den Bosch RJ. Why is self-help neglected in the treatment of emotional disorders? A metaanalysis. Psychol Med 2004;34:959–71. 3. Jorm AF, Griffiths KM, Christensen H, Rodgers B. Effectiveness of complementary and self-help treatments for depression. Med J Aust 2002;176:S84–95. 4. Newman MG, Erickson T, Prseworski A. Dzus, E. Self-help and minimal-contact therapies for anxiety disorders: Is human contact necessary? J Clin Psychol 2003;59:251–74. 5. Russell DH, Shrodes C. Contributions of research in bibliotherapy to the language arts program. Sch Rev. 1950;50:335. 6. Fanner D, Urquhart C. Bibliotherapy for mental health users, Part 1: a systematic review. Health Info Libr J 2008; 25:237–52. 7. Cohen LJ. Bibliotherapy: the experience of therapeutic reading from the perspective of the adult reader. New York University; New York: 1992. 8. Christiansen CH, Townsend EA. editors. Introduction to occupation: the art and science of living. 2nd edition. Pearson Education; Upper Saddle River: 2010. 9. Townsend EA, Polatajko HJ. Enabling occupation II: advancing an occupational therapy vision for health, well-being & justice through occupation. Ottawa: CAOT Publications ACE; 2007. 10. Cohen LJ. Phenomenology of therapeutic reading with implications for research and practice of bibliotherapy. Arts Psychother 1994;1:37–44. 11. Mårtensson L, Hensing G. Experiences of factors contributing to women’s ability to make informed decisions about the process of rehabilitation and return to work: A focus group study. Work 2010;43:237–48. 12. Persson D, Erlandsson L-K, Eklund M, Ivarsson S. Value dimensions, meaning and complexity in human occupation: A tentative structure for analysis. Scand J Occup Ther 2001;8:7–18. 13. Hammell K. Dimensions of meaning in the occupations of daily life. Can J Occup Ther 2004;71:296–305. 14. Wilcock AA. Occupation and health: Are they one and the same? J Occup Sci 2007;14:3–8. 15. Kaltenthaler E, Parry G, Beverley C. Computerized cognitive behavior therapy: A systematic review. Behav Cogn Psychother 2004;32:31–55. 16. Harvey P. Bibliotherapy use by welfare teams in secondary colleges. Aust J Teach Educ 2010;35:29–39.
17. Garland J. Adaptation skills in the elderly, their supporters and carers. Br J Med Psychol 1985;58:267–74. 18. McKinney F. Explorations in bibliotherapy: Personal involvement in short stories and cases. Psychother Theory Res Pract 1975;12:110–17. 19. Stephenson SM, Smith YJ, Gibson M, Watson V. Traditional weaving as an occupation of Karen refugee women. J Occup Sci 2013;20:224–35. 20. National Endowment for the Arts. Reading on the rise: a new chapter in American literacy. National Endowment for the Arts; Washington, DC: 2009. 21. Casini A, Godin I, Clays E, Kittel F. Gender difference in sickness absence from work: A multiple mediation analysis of psychosocial factors. Eur J Public Health 2013;23:635–42. 22. Hensing G, Brage S, Nygård J, Sandanger I, Tellnes G. Sickness absence with psychiatric disorders: An increased risk for marginalisation among men? Soc Psychiatry Psychiatr Epidemiol 2000;35:335–40. 23. Nystuen P, Hagen K, Herrin J. Mental health problems as a cause of long-term sick leave in the Norwegian workforce. Scand J Public Health 2001;29:175–82. 24. Morse JM. Strategies for sampling. In Morse JM, editor. Qualitative nursing research: a contemporary dialogue. Sage Publications; Newbury Park, CA: 1991. pp 127–34. 25. Strauss A, Corbin J. Basics of qualitative research: techniques and procedures for developing Grounded Theory. 2nd edition. Sage Publications; Newbury Park, CA: 1998. 26. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24:105–12. 27. Fridlund B, Hildingh C. Health and qualitative analysis methods. In Fridlund B, Hilding C, editors. Qualitative research methods in the service of health. Studentlitteratur; Lund: 2000. pp 13–25. 28. Reed K, Smythe L, Hocking C. The meaning of occupation: A hermeneutic (re)view of historical understandings. J Occup Sci 2013;20:253–61. 29. Hvalsøe B, Josephsson S. Characteristics of meaningful occupations from the perspective of mentally ill people. Scand J Occup Ther 2003;10:61–71. 30. Leufstadius C, Erlandsson LK, Björkman T, Eklund M. Meaningfulness in daily occupations among individuals with persistent mental illness. J Occup Sci 2008;15:27–35. 31. Andersson C, Eklund M, Sund V, Thundal K-L, Spak F. Women’s patterns of everyday occupations and alcohol consumption. Scand J Occup Ther 2012;19:225–38. 32. Frieswijk N, Stevering N, Buunk BP, Slaets JPJ. The effectiveness of a bibliotherapy in increasing the self-management ability of slightly to moderately frail older people. Patient Educ Couns 2006;61:219–27. 33. Cutchin MP, Dickie VA. Transactionalism: occupational science and the pragmatic attitude. In Whiteford GE, Hocking C, editors. Occupational science: society, inclusion, participation. Blackwell; Oxford: 2012. pp 23–37. 34. Iser W. The act of reading; a theory of aesthetic response. Baltimore: John Hopkins University Press, 1991. 35. Kielhofner G. Dimensions of doing. In Kielhofner G, editor. Model of human occupation: theory and application. Lippincott Willams & Wilkins, Baltimore; 2008;pp 101–9. 36. Hasselkus BR. The meaning of everyday occupation. Slack; Thorofare, NJ: 2011. 37. Fisher AG. Occupation-centred, occupation-based, occupation-focused: Same, same or different? Scand J Occup Ther 2013;20:162–73. 38. Sandelowski M. Sample size in qualitative research. Res Nurs Health 1995;18:179–83.
Reading fiction during sick leave 39. Craik J, Davis J, Polatajko HJ. Introducing the Canadian Practice Process Framework (CPFF): Amplifying the context. In Townsend E, Polatajko HL, editors. Enabling occupation II: advancing an occupational therapy vision for health, wellbeing, & justice through occupation. CAOT; Ottawa: 2007. pp 247–72.
71
40. Ikiugu MN. Meaningfulness of occupations as an occupationallife-trajectory attractor. J Occup Sci 2005;12:102–9. 41. Lal S, Ungar ML, Leggo C, Malla A, Frankish J, Suto MJ. Well-being and engagement in valued activities: Experiences of young people with psychosis. OTJR (Thorofare N J) 2013; 33:190–7.
Copyright of Scandinavian Journal of Occupational Therapy is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
