64 participants with a self-reported active ED read either an unpublished ED recovery memoir or a control text unrelated to EDs over a roughly two-week period and completed the EDE-Q and ANSOCQ one week before and two weeks after reading, as well as responding to three repeating open-ended questions at six timepoints during and at the end of the reading. The intention was to establish whether any change in ED severity was manifested after versus before reading in order to guide a yes/no decision as to whether to publish the memoir. We also sought to investigate the phenomenology of the reading process as it relates to the processes of illness and recovery and individuals’ attitudes to them, to enhance understanding of these response dynamics as well as to guide pre-publication edits to the recovery memoir.
Clinical measures
In this pre-publication study of readers’ responses to an ED-themed memoir and ED-unrelated control text, both ED symptomatology (as measured by the EDE-Q) and ED attitudes (as measured by the AN-specific Stages of Change Questionnaire) were improved for post-reading versus pre-reading for both the experimental (HA) group and the control (TZ) group. Both groups manifested significant positive change with effect sizes that were moderate-to-large (for the EDE-Q) or very large (for the ANSOCQ).
These findings run counter to widespread intuitions (for example amongst many clinicians) that in general reading may have minimal effects on ED-relevant factors, perhaps especially core symptomatology. They also contradict existing evidence suggesting that engagement with texts may have modest or no detectable positive effects on ED-relevant dimensions, including Riestra-Camacho, Carney, & Troscianko’s [9] study of young-adult sports fiction and much research in self-help bibliotherapy. In self-help bibliotherapy studies, even self-help books designed for the sole purpose of eliciting therapeutically valuable responses typically generate only minor to moderate positive effects, with research remaining inconclusive about many basic questions of efficacy and mechanisms. The results also diverge from the strong retrospective self-report evidence in Troscianko’s [5] survey study that ED-specific narratives can have rapid and significant harmful effects on core ED dimensions. Finally, the results also challenge the “similarity thesis” (the expectation that therapeutic ED-related effects depend on thematic congruity between the textual content and the reader’s health situation) since here an effect was found only of time and not of condition—that is, engagement with the ED-themed and the ED-unrelated text had equally positive effects.
The study’s main findings are compatible with a popular belief that engagement with narrative or “literary” texts exerts strong effects on readers—effects typically assumed to be positive in nature. This belief underpins narrative bibliotherapy, which seems to be a relatively common informal practice in one-to-one therapeutic settings, and it is implicit in much humanities research and many public-facing literary art initiatives. However, the results do not unproblematically support the thesis that “books do good”, because it is unclear which features of these two quite different texts may be primarily responsible for the observed improvements, or indeed to what extent the textual features themselves were a major driver at all.
Beyond the impact of text, the absence of mediating effects found in the ANCOVA for either the EDE-Q or the ANSOCQ of any of the main continuous variables (age, professional support duration, highest educational level, BMI change) suggests that the main effects are not significantly susceptible to contributions from demographic or ED severity/support variables, nor indeed from the text choice itself. This null finding further supports the idea that the benefits derive from facets of the text/reader interaction that have yet to be confirmed.
In the remainder of this section, therefore, the free-text response data will be used to generate provisional conclusions as to the mediators of the two main effects and related phenomena. We begin with the computational analysis on three analytical dimensions, offering suggestions as to the drivers of effects related to emotional variance, somatosensory effects, and text/response similarity. Then we conclude by offering an overview structured by five major themes identified in the free-text data via close reading. Unedited illustrative quotations from participants’ responses are included as subsection epigraphs and as part of the main discussion.
Computational analysis of free-text responses
VAD dimensions
“I started this push at recovery a year ago, and feel it has failed. I can’t believe how hopeful I felt back then. I feel so ashamed at how I've behaved in the interim; it seem perverse that recovery should have destroyed my relationships more effectively than anorexia. I don’t think I nor my family had expected quite how much anger and fear and emotionally-charged reforging of me would need to be done - we’ve all been shocked. Pity is easier to give, if not to receive. What do you give someone who is explosively recovering?”
Using the VAD norms to analyse participants’ free responses found a significant within-participants effect for arousal, which increased across the six reading timepoints, and no effects for valence or dominance. The increase in arousal was especially marked for the final timepoint in HA responses, where an unexpected death and mourning process are described. This thematic shift intensifies the general expansion out from ED-centric themes and experiences that characterizes the later stages of recovery, as noted by one HA participant: “Different than the previous sections. More about other life challenges than food-specific ones, which would reflect life after recovery.” Three HA participants at timepoint 6 used language that is particularly rich in high-arousal words, including “rollercoaster”, “climax”, and “inspired and scared”. Arousal increased more steadily across TZ responses between timepoints 3 and 6, and there were no striking examples of high-arousal language in the TZ free-text responses.
Arousal and dominance are typically inversely correlated, but in responses to both texts, the dominance as well as the arousal peak was observed at timepoint 6, suggesting that the narrative progression in both texts—and/or the processes involved in responding to them—had both arousing and control-enhancing elements. The absence of significant change over time in valence values in both groups, and free-response mentions of enjoyment or otherwise that demonstrated no obvious pattern either, suggest that liking and dislike did not play a major role in any reading-related effects. This aligns with findings from a group-reading setting, in which liking or disliking the text being read did not correlate with the perceived value of participation, and liking or disliking the group discussion did not usefully capture the emotional variation in these sessions [35]. One participant whom we contacted because she seemed to be finding the reading emotionally difficult clarified that although she was not enjoying the book very much and it would not be her preference stylistically, the reading and question-answering was encouraging meta-reflection on her thought processes and greater honesty about her current situation. The VAD results and comments of this kind further encourage an interpretation of the main findings according to which the processes of engagement trump the textual features in driving effects in readers—and adds the further hypothesis that enjoyment of these processes is not a major predictor of their value.
Sensory and action-effector dimensions
“Confident becase sometimes, when I give up controlling and micromanaging, wonderful things happen, giving me hope. Yesterday I had a proper and elaborated afternoon snack (not only an apple, but yogurt with rice cakes and peanut butter, and fruit) and unexpectedly I stopped eating when I felt ok. No binge eating on peanut butter as usual.”
As for the sensory and action-effector dimensions, the increase in gustatory values between timepoints 2 and 5 in the experimental group is explicable with reference to the increasing textual emphasis on food and eating. HA naturally contains a much higher density of food-related terminology than TZ. A number of HA participants mentioned being bored, overwhelmed, or otherwise put off by the amount of food-related language in the middle and later sections of the book; these reactions may partially account for the increase in gustatory language for this group.
Olfactory and mouth norms tend to track gustatory ones; concreteness and imageability, which tend to co-vary, may also be driven by the gustatory language. The marked increase on visual ratings in the final timepoint in both groups suggests a possible effect of the use of visual metaphors for increased cognitive “insight” or a more “zoomed-out” perspective at the end of the two books, corresponding to textual elements in both that convey a trajectory of culmination. The similar pattern for “head” may also be tied to the use of visual metaphors for cognition. The decreases in foot/leg and torso at the final timepoint are not readily accounted for, but may be inverse correlations with an increase in cognitive insight. Body-related language mostly concerned difficulties with body image and bodily sensations, worries about fat, and other negative body-related feelings and attitudes common in ED experience.
Text/response similarity
“Interesting. It’s a challenging read and different to what I’d usually go for. But I’m getting a lot from it, and find the writer’s voice engaging and very clear. As she’s struggling to come to grips with some of these very confusing questions, she’s bringing us, the readers, with her on her journey. Am I conscious now? And now? It really is like waking up as soon as the question is asked. Very interesting!”
Analysis of similarity between the texts and responses to them found that the responses for TZ most closely matched the text of TZ, and the same was true of HA, indicating that both texts significantly shaped the language choices of the participants answering questions subsequent to reading them. Without a linguistic corpus to provide a baseline for divergence, relative strengths of these effect for HA versus TZ are hard to assess, but a possibly stronger effect for HA may reflect a greater thematic capture of ED-related material, as suggested by the higher frequency in the TZ group of comments to the effect that they had found the text boring to read or struggled to concentrate on it. 15 HA vs 23 TZ participants mentioned being bored or not engaged or put off at one or more points in the text. These responses may reflect the difficulty of concentrating on non-ED-related stimuli when cognition is impaired by an ED; and this kind of “cognitive constriction” [5, p12] may be especially marked when an ED is associated with malnutrition [36]. As one might expect, valuing cognitive/emotional exploration showed the inverse pattern from boredom/disengagement across the two groups, with more comments to this effect in HA than TZ (20 HA versus 14 TZ). Overall, close reading suggests that TZ was somewhat more polarizing than HA in terms of liking or enjoyment, perhaps in part because of the lower cognitive-emotional capture of non-ED material. These differences, combined with the overall trend towards lower values for TZ than HA on the sensory and action-effector dimensions, suggests that ED-themed material may have a more directive channelling effect on cognition, offering some support for the cautionary angle predicated on the intuition that these texts in some sense “land harder”.
Close reading of free-text responses
Beyond the three types of computational analysis, close readings of the free-response data carried out by ET identified five persistent themes in participants’ responses to the texts and the experiment as a whole: triggering and related phenomena; cognitive-emotional exploration; responses related to identification, comparison, and emulation; responses to the experimental setup; and responses to the dialogical form of the text.
In each case, indications have been given of how many responses aligned with a given theme or subtheme and how many individual participants these responses were provided by. As with any qualitative analysis, however, the categorizations are subjective and should be treated as indicative of broad frequency trends rather than highly precise comparisons. The quotes from which the themes and subthemes were derived can be found in the supplementary materials.
Triggering and related phenomena
“part of me finds it very difficult to read because I don't want to be reminded of the ‘positives’ of the illness (the things that you remember from restricting food intake, how you felt, etc)”
With respect to the potential for overall harm, the category of readerly responses that is most salient within the broad public discourse on EDs and linguistic/cultural artefacts is the concept of “triggering”, a commonly used shorthand for the sudden onset of distress induced by engagement with a stimulus, typically involving feelings or memories associated with a particular traumatic experience or life phase. The experimenters were alert to any uses of the term in participants’ free-text responses during their participation, and a number of observations can be distilled from their uses of this and adjacent terms.
Although the main effects in both groups were positive, some participants’ open-ended testimony gave some indications of possible harmful effects. A number of participants in both groups mentioned “triggering” effects or other similarly difficult responses in the context of their reading. In total, 15 HA participants and 4 TZ participants described triggered or adjacent responses. Three HA participants also remarked that they themselves had not found the text triggering but that other people (including in some cases the participants’ past self) might. These responses are summarised in Table 3; the response sets that inform the thematic analyses are available in the supplementary materials.
Table 3: Triggering and related phenomena in readers’ responses
Identifier
|
Comment quantity
|
Themes
|
Response set 1: participant triggered (HA)
|
18 (15 ppts)
|
- Reminders of perceived positives of ED behaviours
- Comparison of own bodyweight, shape, or BMI with the protagonist’s
- Fear or unease about food/eating, calorie intake, weight gain, and other recovery-related experiences
- Fear of medical advice to stop weight gain / reduce energy intake after weight restoration
|
Response set 2: participant triggered (TZ)
|
5 (3 ppts)
|
- Non-ED linked triggering, including feelings of dissociation and existential dread, aggression, traumatic memories of therapy, and reactions to mentions of sexual violence and criticisms of religion
|
Response set 3: participant not triggered but suggests other readers might be [candidate textual features listed] (HA)
|
4 (2 ppts)
|
- Reactions to detailed descriptions of the protagonist’s pre-recovery food rituals or her mid-recovery calorie increases or introduction of exercise
- Reactions to mentions of the protagonist’s BMI
- Reactions driven by precarity of notional reader’s recovery status, via comparison
|
Response set 4: participant explicitly not triggered (HA)
|
10 (8 ppts)
|
- Reinforcement of desire to recover not relapse
- Motivation, reassurance, or satisfaction in protagonist’s or own progress
- Sadness, frustration or empathy for pre-recovery protagonist or past self
- Relative lack of numerical information a positive
- Boredom or normal level of tension
- Expectations of triggering not realized
|
These responses show how complicated triggering can be. On the one hand, there can be no doubt that textual “triggers” were salient and elicited negatively valent reactions for some participants. These reactions may be attributable in part to the cognitive biases characteristic of individuals with EDs, in which attentional and mnemonic processing is geared towards interpretation of textual elements in ED-aligned ways [15, p83]. In what we might think of as an ED-specific variant on readerly “unreliability” [15, p83], this interpretive configuration can sometimes occur as part of a deliberate effort to self-trigger and exacerbate the ED [5-7].
On the other hand, there was also evidence that many participants felt themselves to be robust in the face of triggering; some distanced themselves from it by reflecting that others might be or that their former selves would have been triggered although their present selves were not. We may conclude that triggered reactions are common and that although some stimulus-response pairings are highly predictable (e.g. weight gain/loss in ED contexts), others are much less so (e.g. Zen meditation as a neutral cue to memories of traumatic therapy) [37]. The testimony provided by our participants also makes clear that triggering is not all-or-nothing: that triggered episodes can coexist with beneficial outcomes from the overall reading experience and that it is often possible to reflect relatively calmly on such episodes, even soon after the fact. Offering structured opportunities for calm reflection may help individuals reduce the potential harm of triggered experiences and potentially even derive good from them. Doing so may thus be a more effective way to build individuals’ intrinsic robustness than providing pre-emptive trigger warnings, which may have the opposite from the intended effects, including by reinforcing the centrality of trauma to a reader’s identity [37].
Cognitive-emotional exploration
“So much of it has resonated with me. It’s given me goosebumps, at times. It’s unearthed a whole range of feelings: sadness, regret, amusement, hope, anxiety. It also feels like it’s helped to lift a cloud that often comes down and obscures my view of what real recovery is.”
The positive EDE-Q and especially ANSOCQ effects found in both groups may be linked to in-depth exploration of mental states, in particular the frequently expressed sense of a psychological progression that involves liberation from entrenched ways of thinking, whether about the nature of human consciousness or about the possibilities of a specific life. In this regard, TZ participants frequently drew interpretive connections between the text’s exploration of Zen meditation and their own ED/recovery experience. As these patterns are of obvious relevance when it comes to cataloguing the cognitive-emotional processes that accompany and may help initiate recovery, they are summarised in Table 4.
Table 4: Cognitive-emotional exploration in readers’ responses.
Identifier
|
Comment quantity
|
Themes
|
Response set 5: cognitive-emotional exploration (HA)
|
31 (26 ppts)
|
- Emotions including sadness, guilt, regret, hope, self-compassion, comfort, anxiety
- Cognitions including (re)assessments of illness/recovery/life, explorations of concepts like control, curiosity about the protagonist’s story, amusement
- Mixed states involving self-recognition and denial, complementing cognitive insight with emotional understanding, experiencing greater cohesion in identity
- Reflecting on reactions to narrative features, including instinctive acceleration in reading for pain avoidance
|
Response set 6: cognitive-emotional exploration (TZ)
|
16 (15 ppts)
|
- Reactions to the narrative as variously interesting, fascinating, inspiring, intriguing, refreshing, calming, and challenging
- Reactions to the open-ended questions as disappointing, pointlessly intellectualized, repetitive, inconclusive, and confusing
- Reassessment of the nature of their own experience, agency, and place in the world
- Experiences of a meditation-like state when reading, with reduced anxiety or increased focus
|
Response set 7: making TZ ED-relevant (TZ)
|
14 (13 ppts)
|
- Reflection on the nature and origins of thought and consciousness, including automatized, ruminative, or judgemental thought patterns
- Over-intellectualization versus embodiment
- Practical benefits of mindfulness practice in recovery
- Broadening perspective and the pleasure of devoting thought to subject matter unrelated to food, body, and exercise
- Attention grabbed by small food-related details
- Appreciation of being “forced” to sit down and read
- Failures to find ED relevance
|
These responses offer valuable insights into how the two texts prompted cognitive-emotional exploration. The responses document a sustained and in-depth engagement with the ideas in the two narratives. Certainly, not all of the responses are positive; nevertheless, there is clear evidence that both the ED-specific and the ED-unrelated narrative can and did provide a scaffolding for cognitions and emotions that relate to recovery and self-understanding, as well as to broader ways of thinking about human experience and the autonomy of the self. Whilst it should not be surprising that narratives can engender cognitive and emotional change (even if there is a remarkable paucity of empirical work on the topic), it is instructive to observe the specifics of how these changes manifest during and around reading in the context of ED experience. The findings align with the suggestion [38] that narrative reading may have comparable effects to cognitive behavioural therapy, allowing individuals to identify, challenge, and replace unhelpful cognitions via both cognitive processes of recognition and reframing as well as emotional processes of empathy, identification, and emotional memories. We provide more detail on identification and related phenomena in the next part of this section on readers’ responses.
In relation to the significant stages-of-change improvement, qualities of the texts and/or the structured engagement with them may have facilitated assessments of illness/recovery-related attitudes. One possibility is that the formal distinctiveness of the texts (relative to more everyday forms of textual narrative) may induce a defamiliarization that is conducive to higher-order thought in which one takes a stance on one’s own thinking. Attention to the formal qualities of the text may be conducive to adopting a meta-perspective on recovery: asking how one feels about the constitutive attitudes and actions (e.g. about one’s fear of weight gain or the ways in which one tries to avoid or engender it) rather than merely experiencing or performing those attitudes and actions. In support of this angle, one participant who reported strong emotional and identification-related responses remarked, “Strange that what resonates with me the most is not the content but the form through which such content is told.”
These reflections and meta-reflections on illness and recovery benefited from a self-aware and expressive group of participants. The responses convey a general sense that recovery follows from a meta-desire to have a desire to recover, and that this attitude is situated in a wider existential framework of consideration of what it means to have a good or a bad life. Participants were on the whole interpretively “hungry” to the extent that they actively sought (or had impressed upon them) details of the text that made them think about their own recovery processes as well as about how the narrative integrated with their wider lives. This was especially striking amongst TZ participants, over a third of whom gave some indication (often quite lengthy) of an effort to make the TZ text relevant to illness and recovery.
In general, the interpretive drive to generate personal ED relevance seemed to have pro-recovery effects. Many participants who found recovery relevance in TZ indicated that the reading had shifted them into bigger-picture thinking, including a critical meta-perspective on how their own minds work. Participating in a study explicitly about ethics-testing an ED memoir is likely to have contributed to TZ participants’ efforts to relate their reading to their illness/recovery, but these responses may also reflect a broader phenomenon in which the ED experience, or even human experience in general, continually attempts to find parallels to itself in widely varying stimuli. This might represent one reason to look for bibliotherapeutic potency in textual features that are not illness-specific in the way that classic theories of bibliotherapy have tended to assume they should be.
Identification, comparison, and emulation
“I have found that once again I identify with many of the feelings and reactions expressed, particularly the final section about walking the tightrope between illness and recovery. Whilst reading, I vacillate between empathising and sympathising with the character and being annoyed at her, which very much reflects the feelings I have about myself and my own illness.”
Identification and adjacent responses were the most commonly reported reaction amongst HA participants and rarely reported in the TZ group. Of the 34 HA participants, 25 mentioned (in many cases repeatedly and/or at length) some form of identification or attempt to identify with the protagonist and/or with the part of her mind labelled “A”. This contrasts sharply with the frequency of such reports amongst TZ participants (only 4 out of 30). The distinction between identification and comparison was blurry (with looser terms like “resonate” hovering between the two): Identification often involved explicit comparison (in what ways are we similar and different?), sometimes described as “measuring oneself” against the descriptions, and comparison more often tended to highlight specific differences within a broader context of similarity. This occurred frequently in HA and barely at all in TZ, with the HA comparisons experienced variously as helpful (9), neutral (6), and difficult or unhelpful (9). Finally, when considering the health-relevant effects of narrative reading, it is easy to neglect two of the simplest and arguably most important types: performing an action or intending to perform it after reading about it. (There is of course a great difference between the two, as highlighted in research on implementation intention frameworks, e.g. [39]). This type of emulatory comparison with the protagonist’s actions was manifest in some HA and TZ responses. Table 6 summarises the responses on the themes of identification, comparison, and emulation.
Table 6: Identification, comparison, and emulation in readers’ responses.
Identifier
|
Comment quantity
|
Themes
|
Response set 8: identification-related responses to protagonist (HA)
|
28 (25 ppts)
|
- Identification or attempt to identify with the protagonist/A
- Self-recognition in the protagonist/A
- Empathy and/or sympathy for the protagonist
- Relatability/resonance of experiences described
- Perceived realism or familiarity of experiences described
- Equivocation between identity and distancing
- Identification of the protagonist with the author
- Widespread absence of explicit comparisons with respect to the protagonist’s body/weight
|
Response set 9: identification-related responses to protagonist (TZ)
|
4 (4 ppts)
|
- Difficulty/ease of relating the protagonist’s concerns or way of thinking to oneself or one’s life and habits
|
Response set 10: comparison of self with protagonist (HA)
|
32 (a) helpful 16, (b) 8 neutral/mixed, (c) 8 difficult/unhelpful) (29 ppts)
|
- Comparison of personality traits, habits, relationships, strength of recovery doubts, approach to / experience of recovery, diagnostic status
- Encouragement to cultivate more self-compassion than the protagonist
- Gratitude or guilt/inadequacy for being less sick than the protagonist
|
Response set 11: motivation to emulate protagonist (HA)
|
14 (14 ppts)
|
- Increased desire, motivation, inspiration, determination to recover
- Feeling fear at the idea of recovering or sadness at the thought of not recovering
- Feeling increased confidence in or readiness for recovery
- Performance of practical recovery actions (e.g. increased daily food intake) as a result of reading
|
Response set 12: motivation to emulate protagonist (TZ)
|
6 (6 ppts)
|
- Attempt or intention to try or resume meditation or self-questioning practice
- Usefulness of ideas/phrases in everyday life
|
HA responses overall were highly expressive of identification with the protagonist, even though this type of response was sometimes qualified with distancing statements or annoyance. The prevalence of the identificatory response is unsurprising given the extent to which EDs, especially AN, reduce individual variation and impose a set of biologically driven starvation-response mechanisms. Feeling oneself to be comprehensively reflected in a textual character is more likely when the pathologically driven features of personality and lifestyle create ready-made equivalences. Few TZ participants related to the TZ protagonist in the vein of identification or related responses, though some attempted this not entirely successfully; the majority of the relatively large number who made the narrative ED-relevant (as discussed in the previous subsection on cognitive-emotional exploration) did so by drawing parallels with processes and experiences rather than by making a self-to-self equation or comparison. Aligning with previous findings that the fictional/nonfictional status of narratives does not affect transportation or belief change [40] and that the distinction is not salient to readers in an ED context [5,7], very few participants mentioned that the fictional/nonfictional nature of the textual personae felt relevant to their reactions. HA included an author’s note describing the text as “a work of lightly fictionalized memoir, or autobiographical inspired fiction”, but most participants seemed to treat the protagonist straightforwardly as a real person, and only one said that the factual status was significant (in a positive sense: “Reading about someone getting steadily better is very nice, especially when you know they’re a real person”).
Strikingly absent from most of these reports of explicit comparison in the HA group were body shape/weight comparisons with the protagonist. Especially following Troscianko’s [5] survey data, we might expect body comparison to be a major line of unhelpful comparative engagement, but experiential elements were much more pronounced here (see the subsection on triggering above for the exceptions). This suggests that some element of the textual construction was discouraging this typically central type of ED-informed thinking, possibly the lack of a consistent first- or third-person focalizer or narrator perceiving or describing characters’ bodies.
As opposed to TZ, where participants described having already trying out some of the practices/ideas in the book, the majority of the emulatory responses in HA were more in the vein of potentiality (I now feel I want or am ready to do this) than actuality (I am now doing this), and the gap even between reinforced intention and action can remain stubborn. However, the fact that two HA respondents conveyed the reality of occurrent change, one of them specifically as a causal effect of reading (“It motivated me to do that big step”), the other at least as an accompaniment and possibly as a cause-effect relationship (“With this reading, I'm doing the 500+ per day”, i.e. adding 500 kcal to her daily diet to initiate recovery, as the protagonist does) suggests that reading may be capable of helping individuals bridge the insight/action gap [41]. One participant’s responses at the six timepoints throughout the reading convey a growing feeling of desire, confidence, inspiration and determination: “I wanna do it too! // I wish someone would come up to me and tell me the same things: “this is how we gonna do it”. I feel ready. // I could do it too, like so many others have done before me. // It can be so easy once you have overcome the first phase of recovery. // More and more inclined to take the plunge and do it. // Recovery is like rebirth. // I am determined to do this”.
Overall, the experience of reading had an undeniable impact on the articulation of recovery-related sentiment, and this seemed to be driven to an important degree by processes of identification and comparison, and to a lesser extent emulation.
Contextual factors: Responses to experimental setup
[Please, wait until tomorrow to carry on reading. Thank you.]
“Roger that. Thank you for these little snippets of kindness and curiosity. Cheers.”
As we ask what interactions of textual features and cognitive processing may be driving the EDE-Q and ANSOCQ improvements, it is possible that the text itself is something of a red herring. The nature of the reading and interpretive processes themselves may exert stronger effects than the linguistic content on which they centre. This would converge with the findings in Carney & Robertson [42] showing that positive effects of reading fiction on mood and wellbeing may emerge only once readers are given the opportunity to reflect on the text they have read, whether through recall or discussing texts with other readers. That is, merely reading a text is not enough for the benefit of the text to be actualized. In the present study, participants were invited to reflect on HA and TZQ via staged questions at six timepoints, thereby providing a context for reflection that was at once sustained and semi-social. On this view, the otherwise puzzling presence of an effect for time and no effect for textual condition becomes explicable as the result of giving readers an ideal scenario for reflective consolidation, where the fact of consolidation is more important than the details of the texts being read. This account also aligns with the “absolute sleeper effect”, in which readers continue to think and be influenced by what they have read in a book long after finishing it [43].
Such results raise the further possibility that the methods designed here to elicit free-response testimony on the reading experience and its effects and context may have substantively changed the processes under investigation. This is to some extent inevitable with any investigative procedure: Volunteering for a research study and reading a book in a specific format, within a specific timeframe, accompanied by a range of self-report tasks, cannot leave the reading experience unaltered relative to recreational reading. The effects of the qualitative aspect of the study design may be wider-ranging than expected, however. The value of responding to recurring questions throughout the reading process was mentioned by several participants, including as transferable to everyday life, while others disliked certain aspects of the question-answering procedure or suggested alternatives, and others again used the questions as prompts to what we might identify as self-coaching. Table 5 summarises the responses on the interpersonal processing dimension.
Table 5: Interpersonal processing in readers’ responses
Identifier
|
Comment quantity
|
Themes
|
Response set 13: positive reactions to questions (HA and TZ)
|
7 (7 ppts)
|
- Appreciation of the consistency of the recurring questions
- Assessments of the questions or the question-answering as interesting, enjoyable, useful, or insight-generating (including as a way to summarise thoughts and feelings)
- Use of question-answering as self-coaching
- Indicators of awareness of the researchers as recipients of the responses
|
Response set 14: negative reactions to questions and suggestions for improvement (HA; no examples observed in TZ)
|
5 (5 ppts)
|
- Experience of the questions as too frequent or too broad
- Preference for the opportunity to comment anywhere in the text, talk to someone directly, or record voicenotes
- Wish to be able to ask the author questions about the book
|
Response set 15: question-answering as self-coaching (HA and TZ)
|
8 (7 ppts)
|
- Reflection on current eating/exercise habits, self-guidance for altering them
- Self-talk to move through dissonance or difficulty
|
It is evident that the dialogic or interpersonal nature of the question-and-answer prompting affected the participants’ interpretive processing. A number of participants in both groups indicated awareness of the researchers as recipients of their responses, including via chatty asides or inclusion of thanks, apologies, and other social niceties. The combination of open-ended prompts to reflection plus the communicative structure of respondent and recipient may have contributed to a process with qualitatively different interpretive outputs relative to reading a text with only the pre- and post-reading questionnaires.
Our first recurring question, “How is your day going?”, functions similarly to the most basic of journaling prompts used by millions of individuals worldwide every day. Some researchers on expressive writing and its therapeutic benefits have suggested that exploration of self through writing is less meaningful if it does not encompass a wide temporal span taking in the moderate to distant past. In a diary-writing study, for example, Green [44, p142] reports that the group who received a long Wordsworth poem to reflect on in their writing showed evidence of a broad range of memories being elicited by the text, whereas the control group’s entries “concentrated overwhelmingly on the daily routines and habitual preoccupations of each participant”, with the strong implication that the control group’s writing was therefore less meaningful or valuable. But the search for origins may often be a misguided endeavour in the context of mental health [45] and a cognitive-behavioural perspective would suggest that the benefits to be derived from conceptual/linguistic interrogation of one’s self and life are likely to accrue predominantly by shifting the interactions between present and future rather than by taking up a new explanatory stance on the past. The present study’s findings are compatible with the idea that meaningful insights and the potential for meaningful change can arise from prompts and focal points that are not primarily past-oriented, and via textually inflected reflection that does not involve significant amounts of recall or interpretation of distant memories.
Textual construction: Dialogue form
“I feel very grateful to have taken part and I think that the concept of the book is great although for me personally it did not work well. It is amazing and intense to get the insights straight in direct speech.”
A final obvious way to account for the improvement on time without a difference by condition is that elements of the texts themselves, but elements distinct from the central thematic emphasis, are responsible for the positive effects. The clearest stylistic feature linking the two texts is the dialogic, interrogative nature of the textual construction. Thirteen participants in the HA group mentioned having found the dialogue form (or the “conversation with [an] anorectic mind”, as one participant put it) effective, some reflecting on its effects at length. The dialogue form also elicited feelings of confusion and other negative reactions for 16 HA participants, and comparable testimony to confusing effects of the formal construction were also found in five TZ participants’ responses. Table 7 shows the responses that touched on the effects of the dialogical or interrogative structures of the texts.
Table 7: Dialogue form mentioned in readers’ responses
Identifier
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Comment quantity
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Themes
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Response set 16: positive/neutral responses to dialogue form (HA)
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14 (13 ppts)
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- Curiosity about interlocutors’ identities
- Engagement by direct speech or dialectic structure
- Perceived congruence (valuable and/or difficult) between ED experience and dialogue form
- Usefulness of “voice of reason” role as counterpoint
- Reassurance in transformation from dialogue to monologue (as unification of self)
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Response set 17: Negative responses to dialogue form (HA)
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19 (16 ppts)
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- Confusion about interlocutor identities
- Perceived incongruence with ED experience
- Experience of dialogue form as frustrating, annoying, unenjoyable, impersonal, disjointed, over-long, self-indulgent, faux-poetic, or surreal
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Response set 18: Negative/mixed responses to dialogue form (TZ)
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5 (5 ppts)
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- Interest
- High cognitive load: tiring, mental workout
- Confusion, frustration, or annoyance
- Need to reread sections
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Participants’ responses to the dialogue form in HA reflected, to varying degrees, all four of the potential effects of this rhetorical choice listed in the Introduction:
- the alternating expression of and challenges to the ED perspective (e.g. “In comparison to other memoirs I have read the ‘B’ voice acted as a kind of ‘leveller’ or reminder of rationality in the conversation”)
- the enhancement of insight through dialogical interplay (especially as a three-way interaction involving the reader, e.g. “as I read the questions [posed by “B” to “A”] I tried to answer them myself. As I am now in the middle of recovery, whereas when I first started reading section one I was deep in my anorexia, I could feel the way my anorexic self would have answered the questions, and compare it to how I would approach them now”)
- the distinct roles of dialogical reflection versus behavioural change (e.g. “i hadn't realised until right at the end that A and B (and C) were different voices in her head. I feel like that was a good way to explore how stuck in your head you can be in the depths of your eating disorder // Emelia was now whole again, it was one monologue rather than multiple voices, and her life was so much bigger than food. But her life wasn't perfect - she still had problems, she still had issues with her body image some times and comparisons. But it was great that she didn't fall back into bad habits.”)
- and the possibility of recovery despite ambivalence (e.g. “The increased coming together of A and B towards the end of the section (them sharing more certainties) was very reassuring, though, in that it encapsulates the shifts of identity that seem so scary right before recovery and that are actually a lot easier to accept (and welcome) and feel more natural once recovery is taking place”)
Dialogue form may also allow for a less passive readerly interaction than a more traditionally constructed memoir: “The question-answer format of this section sort of ensures that it be necessarily more thought-provoking than most anorexia recovery books, and demands more active (and self-critical) engagement from the reader, which I found to be very interesting and useful in terms of imagining my recovery.” This suggests a role for empowering alternatives to the typically didactic nature of the self-help book, which can be paradoxically dis-enabling (Holloway, personal communication). The same participant continued, “I suppose reading this section while in recovery sort of recreates the form of the text itself (the splitting of the speaker into A/B/C etc). Overall I’ve found it quite a therapeutic experience, in that it’s been a bit like performing therapy on myself.” Another participant made the comparison with self-help books explicit, emphasising specifically the greater autonomy invited here: “I’ve appreciated reading a book that is not the typical self-help book, where you're given a templet of things you should do, think and feel: first do A, then B, then C. If I haven't completely misunderstood this book, it opens up to bigger, more philosophical questions (rather than more practical ones), which the reader can think about and figure out herself. And I appreciated that.”
Overall, the reports of significant cognitive demands made by both texts indicate that readers found the interpretive process challenging—in some cases off-puttingly so, in others enjoyably, but perhaps in either case as a major contributor to the cognitive-emotional exploration and meta-reflection discussed earlier. The editing process prior to publication will preferentially target the elements of confusion in HA that can be reduced without compromising the intended ambiguities and complexities.
Limitations and future directions
We have speculated as to the possible mechanisms underlying the main effects found in this study: the significant improvement for both groups on the EDE-Q and (with an especially large effect size) the ANSOCQ. We have identified potential contributors amongst readerly reactions (triggering; cognitive-emotional exploration; identification and related phenomena), contextual factors in the experimental setup (interpersonal processing as guided by the recurring questions), and features of textual construction (dialogue form). More research will be needed to establish causal dynamics with confidence, particularly with respect to the question of the relative contributions of textual versus contextual factors.
In the present study, we used two unrelated texts as experimental and control text, cognisant of the fact that there is no such thing as either a perfectly matched text (any given pair of texts will vary on multiple dimensions) or a perfectly neutral text (every text has complex and partially unpredictable effects on multiple dimensions for different readers at different times). The texts were significantly different in length (HA was much longer), which may have created uncontrolled-for variance in responses. In previous work [42], we used one text in two versions, differentiated by the changes that the author (Franz Kafka) himself made during the writing process, and argued that this method offers a strong combination of comparability and ecological validity. This method is often not viable for texts that are not equipped with the extensive scholarly apparatus characteristic of the Western canon. In practice, other experimental/control combinations are also needed, and future investigations into health-related effects of reading will depend on generating appropriately robust but realistic paradigms.
Using a control group for reading studies can pose difficulties specifically in relation to participant expectations and demand characteristics. Here, HA participants received the type of book they were expecting, while TZ participants were not expecting to read a book about meditation and so may have reacted to it in ways that would be uncharacteristic of individuals who had chosen to read such a book—for example, reading faster, skipping bits, or reading with less interest altogether. Some TZ participants indicated that this had been the case in their reading. Specifying in the recruitment materials that meditation would be the control text subject matter might have helped reduce problems with participants finding TZ boring or dropping out altogether. (The TZ group had 63 dropouts versus 53 in the HA group, though mostly before beginning to read.) However, some level of disappointment not to be assigned to the experimental group may be inevitable.
In future studies we would advise including an initial reading checkpoint at the very start of the text, in order to generate more accurate data about total reading duration. We estimate that the mean duration here was approximately one month, but this involves rough estimates of the gap between the text access being provided and the first checkpoint being reached. There were 3 outliers who took a long time to complete the reading: one TZ participant who took around 10 months, and two HA participants who took 3 and 4 months respectively. Data collection for this study took a total of 13 months, a relatively long duration that may have reduced data consistency both at an individual level (with more potential for changes in life circumstances and events) and across the groups (especially considering that the year between summer 2021 and 2022 was a year of significant change globally in relation to the progression of the Covid-19 pandemic).
The post-reading measures were taken 2 weeks after reading, with no longer follow-up phase. This decision was taken to avoid amplifying recruitment challenges, but in future studies a light-touch follow-up after approximately 3 months would be advisable to test for maintenance or loss of the post-reading effects. Future studies should take into account the possibility that initial positive effects may be short-lived or conversely that short-term negative effects may be precursors to longer-term benefits, potentially via uncomfortable confrontation of difficult realities.