Digital Narrative Bibliotherapy as a Scalable Intervention for Suicidal Thoughts

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.

Third, narratives are implicitly engaging and naturally constructed to make sense of complex circumstances and emotions. Narrative-based bibliotherapy may therefore hold particular value in healthcare communications and in interventions for which patients are expected to learn and apply new knowledge, skills, or behavioral strategies. Likewise, bibliotherapy may be able to support patients' abilities to verbalize their thoughts and feelings by helping these individuals develop a semantic representation of complex psychological processes.

Recently, a growing number of studies have revealed therapeutic benefits of digital mental health resources for people at risk for suicide. Such resources include peer-to-peer internet support networks, web-based individual psychotherapy platforms, and smartphone apps designed to improve the user's sense of self worth. The internet may be a fruitful domain for the development of new suicide interventions, as people with suicidal thoughts may be more likely to seek support online to avoid stigma, readily available methods for the detection of suicide-related discussions online have been validated, and digital interventions can reach a broader population more easily than traditional psychotherapies, including those unable or unwilling to attend in-person appointments. In short, society is in need of effective suicide interventions that are low-cost, engaging, and highly scalable, and internet-based resources seem poised to host such interventions.

Social media platforms provide an opportunity for users to discuss their experiences with mental health difficulties and allow other users to read, comment on, and share these stories with others at no monetary cost. People with suicidal thoughts, behaviors, and related self-injurious concerns tend to utilize social media platforms as a way to communicate and find information about these concerns. The content posted on these platforms, therefore, represents an opportunity to explore whether this form of digital bibliotherapy can help people struggling with suicide. Several recent studies have provided preliminary evidence that digital bibliotherapies can be beneficial for suicidal thoughts. However, many of these studies are qualitative in nature, all examined small sample sizes, and none to our knowledge have employed a randomized controlled design to systematically examine the influence of narrative bibliotherapy on suicidal thoughts.

In the present study, the investigators aimed to fill this gap in the field's knowledge by testing whether reading user-generated stories about suicide posted to a digital social media platform leads to a reduction in the suicidal thoughts of at-risk individuals. The investigators further aimed to test whether such stories are beneficial for people experiencing suicidal thoughts by helping these individuals feel more optimistic (less hopeless) and more connected to others (less isolated).

PARTICIPANTS \& RECRUITMENT

Participants were recruited from the web platform, The Mighty, an online community dedicated to supporting those who face health challenges. Users of The Mighty can subscribe to content posted within sub-communities organized by specific challenges. Website moderators placed a "popup" advertisement for this study on pages that featured content about and related to suicide. Interested users, who had already established a user account with The Mighty, completed an online screening questionnaire that assessed age, race/ethnicity, history of suicidal thoughts, and current intent to act on suicidal thoughts. Participants qualified if they were age 18 or above, reported English as their primary language, thought about suicide in the past year, and reported current suicidal intent of six or lower on a 10-point scale. Eight hundred sixty-four participants met screening criteria and provided informed consent. Of this group, a final sample of 528 participants completed at least one survey including the main outcome of interest, desire to die, during the trial period. Participants were randomized into one of two study groups after providing informed consent, a Treatment condition and a Control condition.

TRIAL PROCEDURES All trial procedures were approved by the Harvard University Institutional Review Board. Qualified participants received instructions about all study procedures by email prior to beginning the trial. Participants randomized to the Treatment condition received one email each day during a 14-day trial period. The email contained a link, which first asked participants to complete a three-item survey assessing self-reported feelings of (a) connectedness, (b) hopefulness, and (c) desire to die. Treatment condition participants were then instructed to read a single user-generated narrative about suicide, confirm the narrative was read, and finally complete the same three-item survey again. Participants in the Control condition received one email each day during the 14-day trial period that contained the three-item survey assessing connectedness, hopefulness, and desire to die only. Participants responded to all survey items using an 10-point Likert-type scale ranging from 1 ("not at all") to 10 ("definitely").

Two weeks after the conclusion of the 14-day trial period, participants in both the Treatment and Control conditions were asked to complete the three-item survey assessing connectedness, hopefulness, and desire to die. After completing the follow-up survey, participants in the Control condition received the same suicide narrative bibliotherapy intervention provided to those in the Treatment condition.

The 14 narratives provided to participants in the Treatment condition each described first-hand experiences with suicidal thoughts and behaviors and highlighted a range of issues related to the authors' struggles. This set of 14 narratives was selected based on pilot research suggesting that they were associated with reductions in suicidal thoughts, included a positive conclusion (e.g., the author discussed recovery), and described the experience of struggle in a relatable way (e.g., "feeling this way is common").

HYPOTHESES The authors tested four a priori hypotheses. First, the authors hypothesized that participants receiving the digital bibliotherapy intervention (treatment condition) would report lower desire to die over the course of the trial period than participants on the waitlist (control condition). Second, the authors hypothesized that the effect of the treatment would be maintained at the 2-week follow-up period. Third, the authors hypothesized that participants assigned to the treatment condition who completed more days of the trial would report lower desire to die (i.e., dose response effect). Fourth, the authors hypothesized that reductions in suicidal thoughts for participants who received the digital bibliotherapy intervention (treatment condition) would be mediated by increased perceptions of connectedness and increased feelings of optimism.