ORIGINAL RESEARCH

BIBLIOTHERAPY

TO DECREASE STRESS AND ANXIETY AND INCREASE RESILIENCE

Varun Sharma, MD,

AND MINDFULNESS:

1#

PILOT TRIAL

Amit Sood, MD, Kavita Prasad, MD,1 Laura Loehrer, 1 Darrell Schroeder, MS,2
and Bauer Brent, MD1

Introduction: Interventions to decrease stress and enhance

resiliency and mindfulness are more likely to be widely
implemented if they can be offered without the need for inperson training. The purpose of this study was to assess
effectiveness of a self-directed Stress Management and Resiliency Training (SMART) program delivered using only written
material for improving stress, resiliency, and mindfulness.
Methods: A total of 37 employees at a large medical center were
recruited and given written material on the SMART program.
Subjects were instructed to practice the skills presented in the
written materials without any additional training. The skills
included education about the neuropsychology of stress and
resilience, training attention to focus in the present moment, and
rening interpretations. Primary outcome measures assessed
resilience, perceived stress, anxiety, and quality of life.

INTRODUCTION
Stress is a ubiquitous problem that is associated with many
acute and chronic medical conditions such as cardiac arrhythmia,1,2 cardiovascular disease,36 impaired immune function,68
and peptic ulcer disease.9 In moderation, stress is healthily
tolerated; excessive stress, however, is associated with poor
medical outcomes,6 unhealthy coping mechanisms,1012 and
symptoms of anxiety and depression.6,13,14 Stressors are difcult
to remove. However, one can enhance one's ability to handle
stress, an attribute often called resiliency.
Stress Management and Resiliency Training (SMART) was
developed as a structured and simple program at Mayo
Clinic, Rochester to decrease personal stress and enhance
resiliency (A.S.V. Sood, D.R. Schroeder, B. Gorman, stress
management and resiliency training (SMART) program
among Department of Radiology faculty: a pilot randomized
clinical trial, unpublished).15,16 SMART is an abbreviated

1 Division of General Internal Medicine, Mayo Clinic, 200 First

Street SW, Rochester, MN 55905
2 Division of Biomedical Statistics and Informatics, Mayo Clinic,
Rochester, MN
# Corresponding author.
e-mail: sharma.varun@mayo.edu; vdsharma.md@gmail.com

248

& 2014 Published by Elsevier Inc.

ISSN 1550-8307/$36.00

Results: Out of 37 employees, 34 (89%) enrolled subjects

completed the study and provided the baseline and follow-up
data. A statistically signicant improvement in perceived
stress, resilience, mindfulness, anxiety, and quality of life
was observed at 12 weeks.
Conclusion: This study demonstrated that a brief, selfdirected program to decrease stress and enhance resilience
and mindfulness provided excellent short-term effectiveness
for enhancing resilience, mindfulness and quality of life, and
decreasing stress and anxiety.
Key words: Bibliotherapy, anxiety, psychological stress, psychological resilience
(Explore 2014; 10:248-252 & 2014 Published by Elsevier Inc.)

version of a therapy developed called Attention and Interpretation Therapy (AIT). AIT and SMART focus on two
aspects of human experience: attention and interpretation.
Human attention tends to focus upon threats.17 These
threats, in modern times, may take the form of hurts,
regrets, worries, and fears that can draw our attention away
from the present moment and into the domains of the past
and the future. This can lead to ruminative thinking,
avoidance, and ineffective thought suppression.18,19 Consequently, untrained attention leads to an increase in perceived
stress. SMART teaches learners to focus their attention in the
present moment and to defer unrened judgments. Learners
are also taught to cultivate and guide their interpretations by
higher-order principles such as forgiveness, acceptance, gratitude, compassion, and life's meaning, instead of supercial
prejudices.
Traditionally, an instructor administers the SMART program to participants in an individual or group session. Three
studies have been completed, which have demonstrated the
feasibility and effectiveness of this program (A.S.V. Sood, D.
R. Schroeder, B. Gorman, stress management and resiliency
training (SMART) program among Department of Radiology
faculty: a pilot randomized clinical trial, unpublished).15,16
Subjects demonstrated signicant reductions in perceived
stress and anxiety, and increases in resilience, mindful
attention, and overall quality of life.15,16

EXPLORE July/August 2014, Vol. 10, No. 4

http://dx.doi.org/10.1016/j.explore.2014.04.002

While resiliency enhancing research is limited, several

stress management programs have proven efcacious.2025
The majority of these programs entail several weeks of
participation in in-person training sessions.26 This may
negatively impact the broader dissemination of the
programs. A self-directed program using only written materials may address issues of portability for a stress management and resiliency training program. Following Cuijpers
and Schuurmans'27 denition, bibliotherapy is a form of
self-directed therapy based on the application of generally
accepted treatments for mental health problems. The protocol involves written information, explanations, and exercises utilized by the patient with minimal or no therapist
interaction.28 Bibliotherapy has been used for decades to
treat mental health problems and has been found
efcacious by several randomized control trials and metaanalyses to reduce depression and several types of anxiety
disorders.29 In the present study, the traditional instructoradministered SMART program was adapted into a form of
bibliotherapy. This study was designed to test the effectiveness of a self-directed, written program with no instructor
interaction to decrease stress and anxiety and enhance
resiliency among employee volunteers from a large academic medical center.
METHODS
The institutional review board (IRB) reviewed and approved
the study protocol prior to recruitment and enrollment. The
study was designed as a single-arm intervention. Inclusion
criteria were as follows: (1) able and willing to participate in
all aspects of the study and (2) provided with, able to
understand, and sign the informed consent. Exclusion criteria
were as follows: (1) recent (within past six months) psychotic
episode, (2) clinically signicant acute unstable neurological,
psychiatric, hepatic, renal, cardiovascular, or respiratory disease that prevented participation in the study, or (3) previously participated in AIT training.
Study Recruitment
The participants were recruited through informational yers
posted on notice boards and e-mail announcements through
a hospital employee list-serve. In total, 90 people responded
to advertisements and 37 met inclusion/exclusion criteria.
Participants were excluded based on self-report of medical
history to the study coordinator.
Study Administration
Respondents were screened for inclusion and exclusion
criteria by the study coordinator over the telephone.
Suitable participants were scheduled a meeting with the
study coordinator whereby informed consent was obtained.
The following instruments were then completed by the
participants at baseline and week 12: ConnorDavidson
Resilience Scale (CD-RISC), Perceived Stress Scale (PSS),
Smith Anxiety Scale (SAS), Linear Analog Self Assessment
Scale (LASA), and Mindful Attention Awareness Scale

Bibliotherapy to Decrease Stress and Anxiety

(MAAS). The participants completed these web-based baseline surveys during the initial meeting with the study
coordinator or shortly after on their own time. At the end
of the 12 weeks, the web-based surveys were mailed to
participants for completion.
The CD-RISC is a 25-item scale with each of the item rated
on a 04 scale, with higher scores reecting greater resilience.30 CD-RISC has been evaluated for reliability, validity,
and factor structure and has been shown to have good
psychometric properties with the ability to distinguish
between participants with lesser and greater resilience.30,49
PSS is an adequately reliable 14-item self-report tool that
provides a global measure of perceived stress.31 Responses
range on a 5-point scale from never to very often. A higher
score indicates greater stress. The PSS correlates well with
measures of stress from life events and social anxiety. LASA
has respondents rate ve single items on a scale of 010.32
It evaluates overall quality of life, overall mental, physical,
emotional, social, and spiritual well-being.32 The Smith
Anxiety Scale (SAS) is a 22-item self-report tool that differentiates between cognitive and somatic anxiety symptoms,
which are similar to most stress symptoms.3335 Responses
range from 0 as bad as it can be to 10 as good as it can be.
MAAS is a 15-item measure that assesses the frequency of
mindful states in day-to-day life, using both general and
situation-specic statements.36
Study Intervention
For the study intervention, participants were given the book,
Train Your Brain Engage Your Heart Transform Your Life
along with three handouts that summarized the contents of
the book. The 443-page book presents the contents of the
SMART program in 13 sections (Table 1). The book has 523
references to peer-reviewed articles.
Table 1. Train Your Brain Engage Your Heart Transform Your Life
Section I
Section II
Section III
Section IV
Section V
Section VI
Section VII
Section VIII
Section IX
Section X
Section XI
Section XII
Section XIII
Appendices

Content summary
Education on neuropsychology related
to stress and resilience
Overview of the SMART program
Concepts and skills of attention training
Concepts related to interpretations
Gratitude
Compassion
Acceptance
Meaning and purpose
Forgiveness
Relationship skills
Meditation and prayer
Growth and transformation
IIV Instruction in relaxation using breath
and body as anchor, physical exercise,
diet, and other tips from the SMART program

SMART stress management and resiliency training.

EXPLORE July/August 2014, Vol. 10, No. 4 249

1.7 at baseline to 8.0 1.5 after 12 weeks (P o .001). No side

effects were reported (Table 3).

Table 2. Demographicsa
Characteristic
Age (years)
Gender
Male
Female
a
b

SMART (n 33 )
b

48.1 11.5
5 (15%)
28 (85%)

Study volunteers were employees Mayo Clinic, Rochester, MN.

A total of 40 subjects were enrolled; 33 subjects completed the study.

Statistical Analyses
Study endpoints included changes in resilience (CD-RISC),
stress (PSS), anxiety (SAS), overall quality of life (LASA), and
mindful attention (MAAS). These assessments were evaluated
at baseline and at week 12. Data were summarized as both raw
scores and also as changes from baseline. Measurements were
compared to baseline using the paired t-test. A sample size of
n 40 was originally selected for this pilot study after
weighing statistical considerations along with logistical and
resource constraints. In general, for a paired t-test a sample
size of n 40 provides statistical power (two-tailed, 0.05)
of 87% to detect a change (pre versus post) of 0.5 standard
deviation units.

RESULTS
Demographics
All participants were employees of Mayo Clinic. Of the 90
respondents, 37 fullled the enrollment criteria: 12 nurses,
three physicians, and the rest allied health staff (four physical/
occupational therapists, two unit secretaries, one P.A.-C, one
audiologist, and 14 others). There were four dropouts, leaving
33 participants who completed the study. The majority of the
study participants were women (85%), with the mean age of
48.1 years (Table 2).
Study Outcomes
Measure of resilience (CD-RISC) increased signicantly from
73.4 10.8 at baseline to 81.8 13.8 at the end of the 12week period in participants (P o .001). Perceived stress (PSS)
decreased signicantly from 25.7 5.6 initially to 19.5
7.3 after 12 weeks (P o .001). Measures of anxiety (SAS)
decreased from 55.5 15.4 at baseline to 41.7 14.9 in
participants (P o .001). Mindful attention (MAAS) increased
from 3.7 0.7 at baseline to 4.3 0.9 after 12 weeks (P
.001). Overall, quality of life (LASA) increased from 7.0

DISCUSSION
This pilot study demonstrates that a self-directed stress
management program using only bibliotherapy for decreasing
perceived stress and enhancing resilience is feasible. The study
also suggests that the intervention has the potential to
improve resiliency, stress, anxiety, quality of life, and mindful
attention. The brief duration and self-directed aspect of the
training are particularly appealing characteristics of the
intervention.
Stressors are a common presence in the lives of many
people. Small amounts of perceived stress can be healthily
tolerated by individuals. However, when stress becomes
prolonged, repetitive, and intense, it may lead to health
problems ranging from cardiovascular disease36 to depression.6,13,14 The expectations of modern society often make it
difcult to reduce the stressors that individuals face on a dayto-day basis. However, we can enhance the ability of
individuals to cope with that stress or their resiliency. By
enhancing resiliency, we are able to reduce perceived stress
and its accompanying anxiety.15,16
A self-directed SMART program has the potential to
reduce stress and increase resiliency in a large number of
people. Several other resiliency training programs have demonstrated positive results in randomized controlled trials.37,38
However, many of these programs require several sessions of
in-person instruction sometimes lasting several weeks.20
26,39,40
This can be expensive and a time commitment that
is difcult for many people to make. Several randomized
control trials of SMART in-person training have been conducted as well. These trials have shown similar effectiveness
for stress reduction and resiliency training in one or more inperson sessions followed by self-directed practice (A.S.V.
Sood, D.R. Schroeder, B. Gorman. Stress management and
resiliency training (SMART) program among Department of
Radiology faculty: a pilot randomized clinical trial, unpublished).15,16 This result is consistent with a meta-analysis that
found guided self-help comparable in reducing anxiety and
depression as face-to-face therapy.29 Observing similar
effectiveness with bibliotherapy as we did with in-person
training is encouraging for our ability to more broadly scale
the program.
Our results are also consistent with several other studies
and meta-analyses that have found bibliotherapy effective in
the treatment of stress,4143 anxiety,28,29,41,43 well-being,43 and

Table 3. Outcome Measures at Baseline and Week 12 Among Those Who Completed the Study (n 33)a
Scale
Connor Davis Resilience Scale
Mindful Attention Awareness Scale
Perceived Stress Scale
Smith Anxiety Scale
Overall quality of life
a

Baseline
73.4
3.7
25.7
55.5
7.0

10.8
0.7
5.6
15.4
1.7

Week 12

o.001
o.001
o.001
o.001
.001

81.8
4.3
19.5
41.7
8.0

13.8
0.9
7.3
14.9
1.5

Scores at baseline and week 12 are summarized using mean SD. Changes from baseline to week 12 were assessed using the paired t-test.

250 EXPLORE July/August 2014, Vol. 10, No. 4

Bibliotherapy to Decrease Stress and Anxiety

depression.28,29,41,4446 Self-directed care can be a useful

strategy to promote health and well-being in people.47,48
After undergoing a one-week training in a self-care program
for bromyalgia, participants in one study described feeling
empowered that they were able to assume more responsibility
in their own healthcare.47 Another study found that self-care
was particularly valuable in treating patients with traumarelated stress who were unable or unwilling to enter into
traditional therapy.48
Many professionals face considerable distress at work. This
has led to increasing rates of burnout, job dissatisfaction,
mental health disorders, and substance abuse.26 Stress
management and resiliency programs would be benecial to
address these problems. However, such training may not be
feasible with the increasing time pressures and the need for
efciency and privacy that professionals face. A self-directed
SMART program may be an accessible and practical way for
professionals and others to reduce their stress and enhance
their resiliency.
This single-arm study is limited by a small sample size and
possible selection bias from the enrollment of motivated
participants. The lack of control arm limits our ability to discern
the possible inuence of a placebo effect on subjects. The brief
follow-up period limits our ability to measure any long-term
effects of the intervention. Further, although our results are
statistically signicant, the condence intervals are overlapping,
thus limiting a more denitive conclusion. Thus, these results
are only preliminary and merits further investigation in larger
controlled clinical trials with a longer period of follow-up.
Future directions for research should examine other methods to enhance the effectiveness of the SMART program.
This may include assessing the feasibility of adding a
supplemental online curriculum. This may also include
examining a step-wise care approach where a participant
would begin self-directed instruction in SMART followed
by their preference of an in-person session or online training.
Future research should also examine participant adherence
and compare SMART to other self-directed therapies.
In summary, a self-directed program using only written
material for stress reduction and resiliency enhancement is
feasible. The program we tested (SMART) shows the potential
to improve resiliency, stress, anxiety, mindful attention, and
overall quality of life for the short-term. Larger randomized
controlled trials with longer duration of follow-up with this
and other interventions are warranted.49

REFERENCES
1. Peacock J, Whang W. Psychological distress and arrhythmia: risk
prediction and potential modiers. Prog Cardiovasc Dis. 2013;55
(6):582589.
2. Vrana M, Pokorny J, Marcian P, Fejfar Z. Class I and III
antiarrhythmic drugs for prevention of sudden cardiac death
and management of postmyocardial infarction arrhythmias. A
review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub.
2013;157(2):114124.
3. Jiang W, Velazquez EJ, Kuchibhatla M, et al. Effect of escitalopram on mental stress-induced myocardial ischemia: results of
the REMIT trial. J Am Med Assoc. 2013;309(20):21392149.

Bibliotherapy to Decrease Stress and Anxiety

4. Neylon A, Canniffe C, Anand S, et al. A global perspective on

psychosocial risk factors for cardiovascular disease. Prog Cardiovasc Dis. 2013;55(6):574581.
5. Houppe JP. Psychosocial stress and cardiology. Presse Med.
2013;42(6 Pt 1):10421049.
6. Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and
disease. J Am Med Assoc. 2007;298(14):16851687.
7. Hall JM, Cruser D, Podawiltz A, Mummert DI, Jones H,
Mummert ME. Psychological stress and the cutaneous immune
response: roles of the HPA axis and the sympathetic nervous
system in atopic dermatitis and psoriasis. Dermatol Res Pract.
2012;2012:403908, http://dx.doi.org/10.1155/2012/403908.
8. Segerstrom SC, Miller GE. Psychological stress and the human
immune system: a meta-analytic study of 30 years of inquiry.
Psychol Bull. 2004;130(4):601630.
9. Overmier JB, Murison R. Restoring psychology's role in peptic
ulcer. Appl Psychol Health Well Being. 2013;5(1):527.
10. Kaur R, Chodagiri VK, Reddi NK. A psychological study of
stress, personality and coping in police personnel. Indian J Psychol
Med. 2013;35(2):141147.
11. Tavolacci MP, Ladner J, Grigioni S, Richard L, Villet H,
Dechelotte P. Prevalence and association of perceived stress,
substance use and behavioral addictions: a cross-sectional study
among university students in France, 20092011. BMC Public
Health. 2013;13:724, doi:10.1186/1471-2458-13-724.
12. Washington TD. Psychological stress and anxiety in middle to
late childhood and early adolescence: manifestations and management. J Pediatr Nurs. 2009;24(4):302313.
13. de Rooij SR, Schene AH, Phillips DI, Roseboom TJ. Depression
and anxiety: associations with biological and perceived stress
reactivity to a psychological stress protocol in a middle-aged
population. Psychoneuroendocrinology. 2010;35(6):866877.
14. Boudarene M, Legros JJ, Timsit-Berthier M. Study of the stress
response: role of anxiety, cortisol and DHEAs. Encephale. 2002;28
(2):139146.
15. Loprinzi CE, Prasad K, Schroeder DR, Sood A. Stress Management and Resilience Training (SMART) program to decrease stress
and enhance resilience among breast cancer survivors: a pilot
randomized clinical trial. Clin Breast Cancer. 2011;11(6):364368.
16. Sood A, Prasad K, Schroeder D, Varkey P. Stress management and
resilience training among Department of Medicine faculty: a pilot
randomized clinical trial. J Gen Intern Med. 2011;26(8):858861.
17. Bishop SJ. Neural mechanisms underlying selective attention to
threat. Ann N Y Acad Sci. 2008;1129:141152.
18. Abramowitz JS, Tolin DF, Street GP. Paradoxical effects of
thought suppression: a meta-analysis of controlled studies. Clin
Psychol Rev. 2001;21(5):683703.
19. Marcks BA, Woods DW. A comparison of thought suppression
to an acceptance-based technique in the management of personal
intrusive thoughts: a controlled evaluation. Behav Res Ther.
2005;43(4):433445.
20. Smith BW, Shelley BM, Dalen J, Wiggins K, Tooley E, Bernard J.
A pilot study comparing the effects of mindfulness-based and
cognitive-behavioral stress reduction. J Altern Complement Med.
2008;14(3):251258.
21. Steinhardt M, Dolbier C. Evaluation of a resilience intervention
to enhance coping strategies and protective factors and decrease
symptomatology. J Am Coll Health. 2008;56(4):445453.
22. Sibinga EM, Stewart M, Magyari T, Welsh CK, Hutton N, Ellen
JM. Mindfulness-based stress reduction for HIV-infected youth: a
pilot study. Explore (NY). 2008;4(1):3637.
23. Bradshaw BG, Richardson GE, Kumpfer K, et al. Determining
the efcacy of a resiliency training approach in adults with type
2 diabetes. Diabetes Educ. 2007;33(4):650659.

EXPLORE July/August 2014, Vol. 10, No. 4 251

24. Ruini C, Belaise C, Brombin C, Caffo E, Fava GA. Well-being

therapy in school settings: a pilot study. Psychother Psychosom.
2006;75(6):331336.
25. Hoffman CJ, Ersser SJ, Hopkinson JB, Nicholls PG, Harrington
JE, Thomas PW. Effectiveness of mindfulness-based stress reduction in mood, breast- and endocrine-related quality of life, and
well-being in stage 0 to III breast cancer: a randomized,
controlled trial. J Clin Oncol. 2012;30(12):13351342.
26. Moskowitz PS. Beyond substance abuse: stress, burnout, and
depression as causes of physician impairment and disruptive
behavior. J Am Coll Radiol. 2010;7(4):313314 [author reply
314315].
27. Cuijpers P, Schuurmans J. Self-help interventions for anxiety
disorders: an overview. Curr Psychiatry Rep. 2007;9(4):284290.
28. Haug T, Nordgreen T, Ost LG, Havik OE. Self-help treatment of
anxiety disorders: a meta-analysis and meta-regression of effects
and potential moderators. Clin Psychol Rev. 2012;32(5):425445.
29. Cuijpers P, Donker T, Johansson R, Mohr DC, van Straten A,
Andersson G. Self-guided psychological treatment for depressive
symptoms: a meta-analysis. PLoS One. 2011;6(6):e21274.
30. Campbell-Sills L, Stein MB. Psychometric analysis and renement of the ConnorDavidson Resilience Scale (CD-RISC):
validation of a 10-item measure of resilience. J Trauma Stress.
2007;20(6):10191028.
31. Cohen S, Kamarck T, Mermelstein R. A global measure of
perceived stress. J Health Soc Behav. 1983;24(4):385396.
32. Locke DE, Decker PA, Sloan JA, et al. Validation of single-item
linear analog scale assessment of quality of life in neuro-oncology
patients. J Pain Symptom Manage. 2007;34(6):628638.
33. Piiparinen RA, Smith JC. Stress symptoms of two groups before
and after the terrorist attacks of 9/11/01. Percept Mot Skills.
2003;97(2):360364.
34. Smith JC. Cognitive Behavioral Relaxation Training: A New System
of Strategies for Treatment and Assessment. New York, NY: Springer;
1990.
35. Smith JC. Creative Stress Management: 1-2-3 COPE System. Englewood Cliffs, NJ: Prentice-Hall; 1993.
36. Brown KW, Ryan RM. The benets of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol.
2003;84(4):822848.
37. Cramer H, Lauche R, Paul A, Dobos G. Mindfulness-based stress
reduction for breast cancer-a systematic review and meta-analysis.
Curr Oncol. 2012;19(5):e343e352.

252 EXPLORE July/August 2014, Vol. 10, No. 4

38. Fjorback LO, Arendt M, Ornbol E, Fink P, Walach H.

Mindfulness-based stress reduction and mindfulness-based cognitive therapy: a systematic review of randomized controlled
trials. Acta Psychiatr Scand. 2011;124(2):102119.
39. Henderson VP, Clemow L, Massion AO, Hurley TG, Druker S,
Hebert JR. The effects of mindfulness-based stress reduction on
psychosocial outcomes and quality of life in early-stage breast
cancer patients: a randomized trial. Breast Cancer Res Treat.
2012;131(1):99109.
40. Singal R, Honig BK, Morison WL, Farmer ER. Hypopigmented,
hyperkeratotic papules in two siblings. Dariers disease. Arch
Dermatol. 1992;128(3):397398 (400391).
41. Jeffcoat T, Hayes SC. A randomized trial of ACT bibliotherapy
on the mental health of K-12 teachers and staff. Behav Res Ther.
2012;50(9):571579.
42. Songprakun W, McCann TV. Evaluation of a bibliotherapy
manual for reducing psychological distress in people with
depression: a randomized controlled trial. J Adv Nurs. 2012;68
(12):26742684.
43. Reeves T. A controlled study of assisted bibliotherapy: an assisted
self-help treatment for mild to moderate stress and anxiety.
J Psychiatr Ment Health Nurs. 2010;17(2):184190.
44. Songprakun W, McCann TV. Evaluation of a cognitive behavioural self-help manual for reducing depression: a randomized
controlled trial. J Psychiatr Ment Health Nurs. 2012;19(7):647653.
45. Naylor EV, Antonuccio DO, Litt M, et al. Bibliotherapy as a
treatment for depression in primary care. J Clin Psychol Med
Settings. 2010;17(3):258271.
46. Wilson KC, Mottram PG, Vassilas CA. Psychotherapeutic treatments for older depressed people. Cochrane Database Syst Rev
2008(1):CD004853.
47. Boals A, Banks JB, Hayslip B. A self-administered, mild form of
exposure therapy for older adults. Aging Ment Health. 2012;16
(2):154161.
48. Hamnes B, Hauge MI, Kjeken I, Hagen KB. I have come here to
learn how to cope with my illness, not to be cured: a qualitative
study of patient expectations prior to a one-week self-management programme. Musculoskeletal Care. 2011;9(4):200210.
49. Ahern NR, Kiehl EM, Sole ML, Byers J. A review of instruments
measuring resilience. Issues Compr Pediatr Nurs. 2006;29(2):
103125.

Bibliotherapy to Decrease Stress and Anxiety