Digital Narrative Bibliotherapy as a Scalable Intervention for Suicidal Thoughts: A Randomized Controlled Trial (Testing Whether Selected Blog Posts Can Improve Well-being)

BACKGROUND In the US, suicide is the 10th leading cause of death among all age groups, and the second leading cause of death of individuals 14 to 34. Despite the enormity of this public health concern, scientific progress has not led to lasting reductions in the suicide rate, which in 2019 was nearly identical to that in the US 100 years prior. Looking beyond the scope of traditional medicine and psychotherapy to identify novel treatments may be critical for improving our ability to ameliorate the problem of suicide.

Scholars have discussed the act of reading as an effective treatment for psychiatric concerns, a concept within narrative therapy known as bibliotherapy, for centuries. Studies investigating the effectiveness of bibliotherapy have found that reading about others' experiences with struggles can be therapeutic. For example, bibliotherapy has been shown to improve hopefulness, reduce symptoms of anxiety, and reduce depressive symptoms. Only a small number of studies have examined narrative-based bibliotherapy as a therapeutic tool to help those struggling with suicidal thoughts, and of these sample sizes are small. However, one such study found that bibliotherapy significantly reduced the number of suicide attempts and nonsuicidal self-harm episodes among adolescents and adults who had recently received treatment for these behaviors. Another such study found that bibliotherapy conducted adjunctively with traditional psychotherapy for depressed adults significantly reduced suicidal ideation for three months following the intervention.

Bibliotherapy has numerous practical benefits when compared with traditional psychotherapies. It is low-cost, brief, and can be conducted easily when face-to-face interventions are not plausible, such as during the current COVID-19 pandemic. The positive effects of bibliotherapy are also generally long-lasting, persisting for anywhere between 3 months and 3 years. Further, bibliotherapy has been shown to be as effective as face-to-face psychotherapy for reducing depression and anxiety symptoms in one large systematic review. Finally, bibliotherapy is shown to normalize the experience of mental health struggles, thereby reducing stigma and allowing patients to feel that they are not alone. Due to the lack of large-scale randomized controlled trials examining the effectiveness of bibliotherapy, there may be additional unknown benefits to this practice, perhaps especially in easily-scalable, online peer-to-peer modalities, as with the present study.

Three key aspects of suicide-related narrative bibliotherapy may be particularly beneficial to those struggling with suicidal thoughts. For one, the first-person perspective of narrative content conveys experiential knowledge about a subject area that is not often discussed openly. By sharing a first-hand experience with challenges, the author of the narrative can communicate specific challenges to be overcome, identify gaps in the reader's knowledge, propose strategies that were beneficial, and provide the reader with a plan for recovery. In doing so, suicide narratives, especially those that showcase recovery-related behaviors and activities (e.g., seeking support), could help people by illustrating the possibility of recovery. Indeed, inspiring optimism is shown to be a key benefit of narrative-sharing for individuals experiencing psychological distress.

Second, suicide narratives may lead to improvements in mental health and wellbeing by increasing social connectedness to a broader community. This may be especially important for suicidal people who face stigma and social isolation that may further exacerbate distress. Moreover, improving connectedness may be critical in remediating problems associated with social isolation caused by the COVID-19 pandemic.