158 Volpe 2013 reading group CPP.pdf

Reading Group Rehabilitation for Patients with
Psychosis: A Randomized Controlled Study
Umberto Volpe,* Fabiana Torre, Valeria De Santis, Francesco Perris and
Francesco Catapano
Department of Mental Health, University of Naples SUN, Naples, Italy
Objective: Group reading activities are often reported to be helpful in a variety of psychiatric
conditions. However, data on the effects of structured reading rehabilitation activities, in both hospital
and community settings for patients with psychosis, are still scarce. Our aim was to investigate the
effects on clinical status, disability, psychosocial functioning and cognitive functioning of a structured
group reading activity, in a sample of hospitalized patients with psychosis.
Methods: We enrolled 41 consecutive patients with psychosis and randomly assigned them to a
structured group reading programme. For all included patients, we psychometrically evaluated clinical
symptomatology, psychosocial functioning and disability, as well as cognitive functioning. All evalua-
tions were repeated at a 6-month follow-up. Repeated-measure multiple analyses of variance were used
to test the effect of the group reading activities on the clinical, psychosocial and cognitive measures.
Results: We found that, after 6 months from discharge, structured group reading activities induced a
statistically significant improvement of cognitive (p < 0.007) and psychosocial (p < 0.008) functioning
in patients with psychosis and reduced their disability (p < 0.005), with respect to the control group.
Furthermore, such programmes are easy to implement and were perceived as extremely ‘interesting’
and ‘useful’ by patients with psychosis.
Conclusions: Rehabilitation programmes focusing on group reading activities should be regarded as a
valid psychosocial rehabilitation tool for psychotic patients with severe mental disability. Copyright ©
2013 John Wiley & Sons, Ltd.
Key Practitioner Message:
• A structured group reading programme induced a significant symptomatological cognitive and psychosocial
amelioration in hospitalized patients with psychosis.
• The improvement was sustained also at the 6-month follow-up, with respect to the control group.
• Structured group reading activities are perceived, by severely ill psychiatric patients, as highly useful,
interesting and pleasant, while they are relatively easy to implement.
Keywords: Reading Group, Bibliotherapy, Psychosis, Psychosocial Rehabilitation
INTRODUCTION
It is long known that severe mental illnesses are associated
to major disability and low quality of life, and despite the
recent progresses of pharmacological therapy for many
psychiatric diseases, the objective of a full recovery for
severe mental illnesses is still to be achieved (Alonso
et al., 2004; Anthony, 1993; Chang, Heller, Pickett, & Chen,
2013). The integration of standard medical approaches
with psychosocial rehabilitation programmes may greatly
foster the fulfilment of this goal (Layard, 2006).
Among the many available psychiatric rehabilitation
approaches, an increasing interest has been recently shown
towards rehabilitation programmes focusing on reading
and narrative approaches in medicine (Divinsky, 2007). In
brief, the approach focuses on group reading of prose
and/or poetry books, with a particular emphasis on sub-
ject’s identification processes and active social engagement,
increasing the sense of ‘agency’, personal growth and the
ability to tell and comprehend one’s personal story
(Abdullah, 2002; Hodge, Robinson, & Davis, 2007; Lehr,
1981; Pardek, 1994).
Bibliotherapy, initially applied in health settings as a
moral treatment with a holistic medicine approach, is today
‘commonly used in the cognitive behavioral therapy milieu’
(Levin & Gildea, 2013). As for psychiatry, reading activities
are most often delivered in the form of manualized
cognitive–behavioural interventions, and this form of
bibliotherapy has long been reported as being useful in a
variety of psychiatric conditions including mood disorders
(Bilich, Deane, Phipps, Barisic, & Gould, 2008; Cuijpers,
1997; Songprakun & McCann, 2012), anxiety (Brenes,
*Correspondence to: Umberto Volpe, MD, Ph.D., Department of Men-
tal Health, University of Naples SUN, Largo Madonna delle Grazie,
80138 Naples, Italy.
E-mail: umberto.volpe@unina2.it
Clinical Psychology and Psychotherapy
Clin. Psychol. Psychother. (2013)
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1867
Copyright © 2013 John Wiley & Sons, Ltd.

McCall, Williamson, & Stanley, 2010; Jones, 2002; Reeves &
Stace, 2005), eating disorders (Högdahl, Birgegård, &
Björck, 2013; Rodríguez-Martín, Gómez-Quintana,
Díaz-Martínez, & Molerio-Pérez, 2013, especially in the long
term Ruwaard et al., 2013), or just even in mental health
distress (Jeffcoat & Hayes, 2012). However, group reading
activities are not only limited to book-based (or, more
recently, Internet-based) self-help therapy, as they can be
implemented in different forms (structured group activities,
reading of self-help booklets, online reading etc.) and with
varying degrees of therapist contact (ranging from none,
limited or full contact), and no wide consensus on content
and structure rehabilitation programmes focusing on
reading activities has been achieved yet. Although group
bibliotherapy has been reported to be more effective than
a waiting list for psychiatric patients (den Boer, Wiersma,
& Van den Bosch, 2004; Smith, Floyd, Scogin, & Jamison,
1997), it is often perceived as useful only for milder psychi-
atric conditions (Macdonald, Vallance, & McGrath, 2012;
Robertson, Wray, Maxwell, & Pratt, 2008). Some authors
(Montgomery, 2001; Parslow et al., 2008) pointed out that
the effectiveness of bibliotherapy may depend on unspecific
factors (such as operators’ time/effort and level of access to
the activities), and negative results have also been previ-
ously reported (Anderson et al., 2005; Joling et al., 2011).
Thus, no definitive conclusions on the impact of bibliother-
apy group activities on cognitive and psychosocial
functioning of patients with mental disorders can be drawn.
The aim of the present study was to investigate the
effects of a structured bibliotherapy group programme
on psychosocial and cognitive functioning in a group
of hospitalized patients with severe psychosis, after a
6-month follow-up.
METHODS
Subjects
Subjects were recruited among patients consecutively
admitted to the inpatient ward of the Department of Mental
Health of the University of Naples SUN. The clinical diag-
nosis of functional psychosis (either schizophrenia,
schizoaffective disorder or bipolar disorder) was based on
the DSM-IV-TR criteria (APA, 2000) and confirmed by the
Structured Clinical Interview for DSM-IV-Patient version.
Patients had to fulfil the following inclusion criteria: (1)
operationalized definition of ‘severe and persistent mental
illness’, according to the criteria proposed by Ruggeri,
Leese, Thornicroft, Bisoffi and Tansella (2000), which
included (1.a) diagnosis of any non-organic (either affective
or non-affective) psychosis, (1.b) duration of treatment
longer than 2 years and (1.c) a global assessment of
functioning (APA, 2000) score of 70 or less; (2) right-hand-
edness, verified using the Oldfield Questionnaire (Oldfield,
1971); (3) negative history of head trauma with loss of
consciousness, epilepsy, substance abuse or dependence
in the year preceding the recruitment; (4) age range of
18–65 years; (5) educational level not below 5 years;
(6) a Mini-Mental State Examination (Folstein, Folstein,
& McHugh, 1975) total score of ≥16; and (7) written
informed consent to participate in the experimental
procedures.
Patients were randomly attributed either to the reading
or to the control group by a researcher (F.P.) who
remained blind to patients’ clinical diagnosis. The control
group participated in standard clinical activities (which
included a behavioural programme to increase adherence
to pharmacological treatment and an expressive art
laboratory, biweekly). The local University Ethical
Committee approved the experimental procedures, which
conformed to the ethical principles for medical research
endorsed in the Declaration of Helsinki.
Group Reading Procedures
We adopted a group setting and chose the ‘serious
literature materials’, as recently proposed by Dowrick,
Billington, Robinson, Hamer and Williams (2012). In
brief, reading groups were established biweekly. Each
session lasted about 90 mins and had a fixed structure
(encompassing a brief recap phase, a prose reading
phase and a poetry reading phase). All materials were
read aloud by patients within the session, and two
facilitators encouraged discussions; however, participa-
tion to reading and interactive discussion was left to
a voluntary participation of group members, and each
of them was free to interact in relation to what was
happening in the text (in terms of narrative, characters,
places, setting, language etc.) and among themselves
(in terms of personal feelings, memories, thoughts,
experiences etc.).
According to Divinsky (2007), we used a specific distri-
bution of reading materials across sessions: illness experi-
ences, hospitalization, hospital discharge and daily life
experiences. Monthly follow-up sessions were planned
ahead. All psychometric evaluations were performed at
baseline and at a final 6-month end point.
Data Collection
Data were collected from 1 March 2012 to 30 September
2012. Basic socio-demographic information (including
sex, age, education and marital status) was retrieved using
an ad hoc schedule. Socio-economic status was calculated
according to a simplified version of the four-factor
Hollingshead index of social status (Hollingshead, 2011).
U. Volpe et al.
Copyright © 2013 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2013)

Subjective Ratings Concerning Group Activities
At the end of each group reading session, patients were
asked to fill in a set of Likert scales (ranging from a mini-
mum of 0 to a maximum of 4) to assess their ‘degree of
cooperation’ to the experimental procedures (i.e. willing to
perform the activity), ‘performance’ within the group (i.e.
feeling able to perform the activity), ‘interaction’ with the
group (i.e. perceived reciprocal influence among group
members), ‘pleasantness’ (i.e. how pleasant was the reading
activity perceived), ‘usefulness’ (i.e. how useful was the
reading activity perceived) and ‘interest’ (i.e. how
interesting was the reading activity perceived).
Psychopathological Evaluation
At the time of admission, DSM-IV standardized diagnosis,
age at illness onset, duration of illness, duration of last
admission to a psychiatric ward and pharmacological
therapy were recorded.
The Brief Psychiatric Rating Scale (Lukoff, Liberman,
Nuechterlein, & Ventura, 1986) was used to evaluate
general psychopathology; in brief, the 24-item version of
the scale allows rating of subjective symptomatology,
objective symptomatology and pathological behaviours
on a 0–7 range of severity.
The Personal Health Questionnaire Depression Scale
(Kroenke, Spitzer, & Williams, 2001) was used to evaluate
the affective symptomatology; the scale is a self-administered
instrument that verifies the presence of nine depressive
symptoms, ranging from 0 (absent) to 3 (every day).
Psychosocial Evaluation
Psychosocial functioning was evaluated by means of the
Personal and Social Performance Scale (Morosini,
Magliano, Brambilla, Ugolini, & Pioli, 2000); the scale is a
clinician-reported measure of severity of personal and social
dysfunction, which explores four main areas of psychoso-
cial functioning (i.e. socially useful activities, including
work and study; personal and social relationships; self-care;
and disturbing and aggressive behaviours).
To assess patients’ disability, we used the Disability Assess-
ment Schedule (WHO, 2001), which is a fully structured self-
administered 12-question multidimensional questionnaire,
which includes six domains (i.e. understanding and commu-
nicating, getting around, self-care, getting along with others,
household and work activities and participation in society).
Cognitive Functioning Evaluation
The Schizophrenia Cognition Rating Scale (SCoRS; Keefe
et al., 2006) is an interview-based assessment of day-to-day
cognitive functioning, which explores the following
domains: attention, memory, reasoning, problem solving,
working memory, language production and motor skills. It
is administered separately to the patient and to an informant
and takes approximately 12mins to complete. After the
interview has been administered, the interviewer ranks the
patient on 18 items on a 4-point scale (1=least difficult;
4=most difficult) and gives a global score, based on the
responses of both the patient and informant as well as the
interviewer’s observations of the patient.
Statistical Analyses
Differences on socio-demographic characteristics of the
experimental and control groups have been tested by means
of an analysis of variance (ANOVA). For categorical
variables (i.e. sex, marital status and socio-economic status),
the chi-squared test was used.
Psychotropic drugs are long known to exert some influence
on attention, expressive abilities and memory (Culpepper,
2007); thus, to exclude a possible bias on cognitive
functioning variations due to differences in pharmacological
status, we used chi-squared test to evaluate differences in
neuroleptic usage. If a statistically significant difference
between the two experimental groups was found, a neuro-
leptic dose was planned to be used as a covariate in all
subsequent analyses.
A ‘repeated-measure’ multiple ANOVA (MANOVA) was
used to test the differences between baseline and 6-month
follow-up (the categorical factor was the type of ‘group’,
whereas the within-group factor was the ‘time’ elapsed
between baseline and follow-up evaluation) on psycho-
pathological and psychosocial functioning indices. A
repeated-measure MANOVA was used to test the differ-
ences between baseline and 6-month follow-up (with the
same categorical and within-group factors, as mentioned
previously) on the different ‘domains’ of the SCoRS
interview. To evaluate the differences on subjective indices,
we submitted these values to a repeated-measure ANOVA
(in which the time elapsed between baseline and 6-month
follow-up was used as the within-subject factor).
When a statistically significant ‘main effect’ and/or ‘in-
teraction’ in MANOVAs was found, Tukey’s post hoc tests
were performed when appropriate, to compare group
means and control for type I errors.
For all statistical analyses, the software STATISTICA
(version 10; StatSoft Inc., Tulsa, Oklahoma, USA, 2012)
was used, and the level of significance was set at p < 0.05.
RESULTS
We initially aimed to recruit 50 patients (25 subjects for
each experimental group); however, due either to initial
Reading Group for Psychosis

lack of cooperation or changes in their drug regimen at
end point, our final sample was made of 41 patients (21
in the reading group and 20 in the control group). A ma-
jority of the patients had a diagnosis of schizophrenia
(n = 19), followed by those with schizoaffective (n = 16)
and bipolar disorder (n = 6); the demographic and clinical
characteristics of the experimental sample are presented in
Table 1. The two experimental groups did not significantly
differ in age, education, Mini-Mental State Examination
total score, age of onset and duration of illness
(F8,33 = 0.74; p = 0.65). Chi-squared tests revealed that the
two groups did not significantly differ in sex distribution,
marital status, socio-economic level, diagnostic distribu-
tion or neuroleptic drug use.
Psychopathological Indices
An improvement in Brief Psychiatric Rating Scale total
scores was observed in both experimental groups at
follow-up, with respect to the baseline (Table 2), although
it turned out to be statistically significant for the reading
group only (F1,20 = 56.61; p < 0.00001).
The analysis of Personal Health Questionnaire Depression
Scale total scores revealed an improvement of the affective
symptomatology over time in both groups (F1,40 =81.11;
p < 0.0001), but the changes were more marked in the
reading group (Table 2).
Psychosocial Functioning
The results obtained at the Personal and Social Performance
Scale highlighted an improvement of psychosocial
functioning in both experimental groups at the final fol-
low-up, although the improvement was significantly
greater in the reading group, with respect to the control
group (F1,39 = 7.29; p < 0.008; Table 2).
The Disability Assessment Schedule scores also revealed
that patients attending the reading group obtained a more
marked reduction of disability over time, with respect to
the control group (F1,39 = 3.07; p < 0.005; Table 2).
Cognitive Functioning
A statistically significant interaction (group × time × ‘SCoRS
dimension’: F6,234 = 3.02; p < 0.007) among the two experi-
mental groups was observed after 6 months concerning
their cognitive functioning; however, at the final follow-
up, all SCoRS dimensions turned out to be significantly
reduced only in the reading group, when compared with
the control group (Table 2).
Subjective Ratings
Subjective reports on the activity confirmed that group par-
ticipants significantly increased ‘cooperation’, ‘interaction’
and ‘group performance’, when comparing such scores at
final follow-up with those at baseline (F11,429 = 1.87;
p = 0.04); furthermore, nearly all subjects included in the
reading group reported that the reading group activity
was perceived as highly ‘pleasant’, ‘useful’ and ‘interesting’.
DISCUSSION
We found that patients with psychosis, after having
attended a reading group programme, improved in their
clinical symptomatology and cognitive and psychosocial
functioning, with respect to patients who did not attend
such structured activity. Patients who attended the group
also reported that the reading activity had a positive
impact on group cooperation dynamics and that it was
perceived as highly pleasant, useful and interesting.
Previous studies reported that various types of bibliother-
apy had some beneficial effects in patients with anxiety
(Brenes et al., 2010; Jones, 2002; Parslow et al., 2008; Reeves
& Stace, 2005) and depression (Ackerson, Scogin,
McKendree-Smith, & Lyman, 1998; Anderson et al., 2005;
Bilich et al., 2008; Briggs & Pehrsson, 2008; Dowrick et al.,
2012; Joling et al., 2011); the beneficial effect of cognitive–
behavioural bibliotherapy for depressed patients was found
to be effective also in a metanalysis on the topic (Cuijpers,
1997), and it was reported to remain stable even after 3 years
(Smith et al., 1997).
However, we applied a group reading protocol on a
severely ill patient population with high levels of disability
and reported a significant improvement not only of their
Table 1. Demographic and clinical characteristics
Reading group
(n = 21)
Control group
(n = 20)
Sex (male; %) 42.8 50.0
Age (years) 43.1(3.1) 44.2(3.3)
Education (years) 11.1(0.7) 11.4(0.79)
Marital status
Married (%) 38.1 35.0
Single (%) 47.6 45.0
Divorced (%) 14.3 20.0
Socio-economic status
High (%) 19.0 15.0
Medium (%) 57.1 65.0
Low (%) 23.9 20.0
Age of onset (years) 21.3 (1.3) 21.6 (0.8)
Illness duration (years) 21.1 (3.1) 21.9 (2.9)
MMSE total score 22.9 (0.5) 21.8 (0.5)
Values of age of onset, illness duration and MMSE total score are reported
as means (SD). No significant differences on socio-demographic variables,
between the two experimental groups, were found.
SD = standard deviation; MMSE = Mini-Mental State Examination.
U. Volpe et al.

affective symptomatology but also of their cognitive and
psychosocial functioning, with respect to the control group.
A possible interpretation of the mechanisms underlying
the observed improvements may involve the effect that
structured reading may have on the functioning of specific
cerebral regions: structural and functional abnormalities
of temporal and prefrontal cortices have long been postu-
lated as a functional basis for many clinical and patho-
physiological aspects of psychosis (Suzuki et al., 2005);
studies on the topic reported that reading activities may
change the functioning of brain areas, particularly those
involved in semantic memory-based mechanisms and
the creation of morphosyntactic rules (Kuperberg, 2007),
and this may in turn exert some positive influence on the
activity of fronto-temporal circuitries. Further to these
possible neural mechanisms, the possibility that positive
social interactions within the reading group may exert
some positive influence on cognitive functioning and
improve the emotional modulation has been previously
suggested (Gallese, Keysers, & Rizzolatti, 2004; Herbert
et al., 2009; Perfetti & Frishkoff, 2008; Phelps, 2004;
Therriault & Rinck, 2007) and cannot be excluded.
However, these interpretations remain speculative, and it
would need the implementation of proper functional neuro-
imaging studies to be proven. Further limitations of our
study were connected to a certain degree of diagnostic
heterogeneity: to ensure a proper randomization of the
patients, we included all psychotic patients consecutively
admitted to our psychiatric ward, and we were not able to
explore the impact of the group reading activities in more
homogeneous diagnostic subgroups, due to lack of statisti-
cal power. Further to this, we followed up our experimental
group for 6 months only, and conclusions on a possible
longer-term effect of group bibliotherapy have to be
confirmed in community studies, designed with longer fol-
low-up and more homogeneous diagnostic categorization.
In conclusion, despite the formerly recognized limita-
tions, our study demonstrated that structured group
reading activities may exert some positive influence on clin-
ical symptomatology and cognitive and psychosocial
functioning in patients with psychosis. Thus, in the future,
structured programmes focusing on group reading
activities should be regarded as a valid psychosocial
rehabilitation tool for patients with severe mental disability.
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T0 T6 T0 T6
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BPRS total score** 49.95 (15.48) 36.21 (17.43) 51.2 (17.75) 41.2 (15.69)
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*p < 0.01 (between-group multiple analysis of variance significant difference at 6-month end point).
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