Using bibliotherapy with youth, to explore their experience with suicidal thoughts
Written by EMDR certified trauma therapist Melissa Barsotti, LCSW, a private practice therapist in San Diego, California.
Permission to include excerpts from book provided by author of Stay Alive, Oshri Liron Hakak
Illustrations by: Andrea Ceballos García
Bibliotherapy is the practice of using books within therapeutic contexts, sometimes referred to as biblioguidance, bibliocounseling, literatherapy, or reading therapy (Pehrsson & McMillen, 2007). Clinical bibliotherapy is a practice used by mental health practitioners to assist clients throughout the therapeutic process, especially at the beginning of therapy when there is much to learn about the mind and body connection, emotions, etc. Clinicians often assign bibliotherapy material to clients when providing psychoeducation, and encouraging self-reflection, among other uses for bibliotherapy.
Fourteen years ago, when I first became a therapist, I had the honor of working with children ages five through eighteen. I often used bibliotherapy with children and adolescents as a way of introducing sensitive mental health material in a non-threatening way. A frequent barrier I often encountered was the scarcity of books on all topics of mental health, especially the experience of suicidal thoughts as a result of depression. Luckily, there are artists like Oshri Liron Hakak, who takes pride in creating beautiful works of art on important mental health issues, specifically written and illustrated for youth. Although the target population of Oshri's book Stay Alive, may be youth over the age of twelve, adults may also connect to this book, as it is written as a poem, and illustrations are beautiful and embracing of the diversity of humanity.
When an individual expresses thoughts of suicide, it is crucial to STOP and LISTEN.
Stay Alive is a gentle way of opening the door to conversations about thoughts of suicide. It is important to know that suicidal thoughts are a symptom, and not the full picture of an individual's experience. To fully understand what someone is experiencing, we have to explore, and have a curious open mind. We have to be mindful to hold an inviting welcoming and non-judgmental space for our youth to feel comfortable in coming to us about their experiences. It is also important to remember that depression may often be an appropriate human response to experiences of adversity.
To further understand suicidal thoughts, we can look to a qualitative study on the following research question: how do young people make sense of their own experiences of suicidal distress (Marzetti, McDaid, & O'Connor, 2022, p.3)? This qualitative study showed that all 24 participants experienced suicidal thoughts by age 14. Participants described the development of suicidal thoughts as "an almost rational response to long histories of adversities causing deterioration in their mental health (Marzetti, McDaid, & O'Connor, 2022, p.3)." One participant of the qualitative study shared the following:
"I would say it's always been there. I remember being 12 years old and
thinking 'god, I have to go through another ....70 years of this? It's like that thought
is in your head now, like I wish I was dead. And then...slowly just more consistent,
it's more like the first thing you think of when something bad happens, but you
know, you don't see a future, you just see...like you're going to get to a point where
it's either going to suddenly be better and something you're not going to think
about anymore, it's going to be something you wouldn't even imagine doing, or
it's eventually going to get you (Marzetti, McDaid, & O'Connor, 2022, p.3)."
In summary, participants of this qualitative study described experiencing "adversity as a causal chain, from which suicide appeared to them the only escape. These narratives seemed to position suicide as a rational option given the ways their lives felt unlivable (Marzetti, McDaid, & O'Connor, 2022, p.5)."
Stay Alive is a book about hope, reminding the reader of the beauty of nature. Stay Alive also provides important information about emotional pain, specifically pages 33-37, where the following is shared:
"because if you study the weather, you'll notice no storm lasts forever...and things
get better. So feel what you feel as a tree feels a drought before rain, or as the
moon feels the darkness of its monthly wane (Oshri, 2022)."
An adult reading with a child/adolescent can explore the child's connection to the illustrations, with gentle questions such as 'have you ever felt this way? would you like to draw your own picture of how you feel your pain?'
Lastly, on page 48, Oshri includes important resources, including the National Suicide Prevention Lifeline contact information (988), as well as a website to find a helpline outside of the U.S (findahelpline.com).
Although I do love and recommend clinicians, teachers, and parents to have their own copy of Stay Alive, I do have the following suggestions for authors on the topic of suicidal thoughts:
Collaborate with a mental health therapist who specializes in depression and suicidal thoughts, to develop helpful questions and guidance for adults. This information could be at the end of the book, as part of a helpful resources section.
Like Oshri, include beautiful illustrations that are universal and diverse. Illustrations are opportunities for connection and conversation.
Don't be quick to provide hope and positivity. Those of us with suicidal thoughts may often struggle to stay positive, and even become bothered with positivity. Instead, open up the story with curiosity, questions, and exploration.
An illustrative journal can go a long way
imagine the book starts with a picture of a bottomless pit, a dark deep hole
a journal prompt can include the following questions:
When you feel empty and alone, what are the thoughts that take up space in
What does it feel like to have these thoughts?
What do these thoughts make you want to do?
What has made you feel better?
What has made you feel worse?
Do you remember when you started to feel this way?
I wonder if something happened...
Would you like to share your story?
If you could snap your fingers and make things better, what do you imagine would
be different in your life?
5. Use metaphors in your story to provide the reader with psychoeducation about the human experience of pain and suffering. Suicidal thoughts are not "bad." Suicidal thoughts are messages, clues, signs that a human needs help and connection.
If you have read a helpful book of fiction or nonfiction related to suicidal thoughts, please share your suggestions with me. I would love to read the suggested books and offer my thoughts in a future post. If you would like to contact me, please email me at: firstname.lastname@example.org. Title the subject of the email with: FOR BLOG-POST ON SUICIDAL THOUGHTS.
Thank you kindly for reading!
About the Author of Stay Alive:
Oshri Hakak is an author, artist and musician based in Los Angeles, CA, who creates to uplift. He especially loves creating illustrated books about unconventional topics, for both children and grown-ups, to help people live more adaptive and happy lives. His books can be found on ButterflyonBooks.com and Amazon.
Hakak, O. (2022). Stay Alive
Marzetti, H., McDaid, L. and O'Connor, R. (2023), A qualitative study of young people's lived experiences of suicide and self-harm: intentionality, rationality and authenticity. Child Adolesc Ment Health. https://doi.org/10.1111/camh.12641
Pehrsson, D., McMillen, P. S. (2007). Bibliotherapy: Overview and implications for counselors. Professional Counseling Digest 2.