Article on self-help books and therapy. Thoughts?

[brain hugger]

Just ranting and introducing a topic for discussion. This article downplays therapy and ignores this part of the article (ugh):

Researchers say you might as well be your own therapist
"Studies that targeted PTSD or depression (k = 4) had significantly larger effect sizes than those that targeted anxiety or stress, g = −0.717 (95% CI −1.259 to −0.175) versus g = −0.023 (95% CI
−0.276 to 0.230) respectively, (p = .023), and in 75% of studies that targeted PTSD or depression the therapist-directed arm was more effective than the self-help arm."

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[WisNeuro]

Meh, even despite that, I am not a fan of meta-analyses that pool everything under the sun together. We know that certain treatments, therapy/medications, differentially affect different disorders. This was just a lazy meta-analysis, which is probably why it's buried in some crap journal instead of psych bulletin. Garbage in, garbage out.

 

[smalltownpsych]

They said that most of the self-help involved some professional direction. I direct patients all the time to use various aspects of self-help. I have personally utilized behavioral principles and psychological information to improve coping and minimize anxiety through my own direction as have family members and friends. That is self-help. My patients tend to be the ones who need more help than they can access on their own though.

 

[Ollie123]

It's actually a reasonably well-respected outlet, just a narrow specialty journal (hence the low IF). It's a very small meta, but there just isn't a lot of work in this area. I think the main conclusion is just that we need more studies - with a k that small and decent variability, I don't trust any outcomes (positive or negative).

I can see this from both sides. The popular press article is weak, but there are dozens of those a day. I haven't pulled the meta itself yet. I suspect they drew stronger conclusions than are warranted. That said, I do think it's important to strike a balance. Too many psychologists seem categorically opposed to the idea that self help or efficient delivery methods are bad. We do some work in this area and inevitably get at least one "DEY TOOK ER JOBS" question when presenting. The current model is unsustainable and has shockingly little research to support it's advantages.

 

[MCParent]

Too many psychologists seem categorically opposed to the idea that self help or efficient delivery methods is bad. We do some work in this area and inevitably get at least one "DEY TOOK ER JOBS" questions when presenting. The current model is unsustainable, has shockingly little research to support for it's advantage

Yup. Health care is changing and we can be at the table or on the plate.

 

[Justanothergrad]

As WisNeuro said, use of a non-random effect model for meta-analysis is likely an inappropriate statistical assumption.

Yup. Health care is changing and we can be at the table or on the plate.

And leave it to psychologist to form a meeting or series of committees about it to decide which is better. It amazes me how non-proactive we are as a field about advancing healthcare and our place in it. But.... thats another thread.

 

[PsyDr]

None of this bull**** is new. Burns' book had multiple empirical studies, waaay back in 1980. Notice how the field went away 40 years ago? Me neither.

 

[foreverbull]

I didn't glance at the study, but I'm interested in the sample of people who did the full self-help regimen without dropping out. If someone has the dedication, motivation, and drive to maintain regular self-help practice strategies over time, they're the prime people we want in therapy because they would practice the tips and strategies we teach and suggest! They'd be helped by self-help stuff and their own self-awareness work with minimal direction, and they'd also likely be helped by therapy as well because of high motivation to change. This doesn't seem to be a solid argument to knock therapy effectiveness itself, but I think this could speak more to how powerful self-motivation and dedication to a regular positive self-care practice could be in one's life. But realistically, how many people have the motivation and drive to independently keep up a self-help program with no support? It's probably more realistic for people to engage in regular yoga, exercise, or meditation than manualized self-help. I think therapy is a more realistic way of engaging people in positive self-care than an independent self-help program, so I don't think our field would be affected much by this kind of article, even if the research design was sound.

In short, client factors account for a huge proportion of therapy outcomes, so high motivation to change and dedication would go far in a regular daily practice for certain issues in the self-help domain, too. This makes sense to me.

 

[brain hugger]

I agree that medications, books, and apps can be helpful, alone or in combination with other MH tx (and in a way, we're lucky, since we have more sources of support to pull from).

Where my frustrations lie is in how, articles such as these, raise up quick/convenient (and somewhat socially isolative) approaches, while discounting the impact of the interpersonal part of therapy (even saying that the therapist contribution is less than 1%). After having watched people in therapy (in couples and in groups) get out of their patterns of stuckness/bitterness/self-hate (or other-hate!) by working through and reflecting on their relationships together, I get irritated when the relational piece (and most often the difficult piece) is minimized.

 

[Ollie123]

I agree that medications, books, and apps can be helpful, alone or in combination with other MH tx (and in a way, we're lucky, since we have more sources of support to pull from).

Where my frustrations lie is in how, articles such as these, raise up quick/convenient (and somewhat socially isolative) approaches, while discounting the impact of the interpersonal part of therapy (even saying that the therapist contribution is less than 1%). After having watched people in therapy (in couples and in groups) get out of their patterns of stuckness/bitterness/self-hate (or other-hate!) by working through and reflecting on their relationships together, I get irritated when the relational piece (and most often the difficult piece) is minimized.

Fair enough, though that is ultimately an empirical question. I don't think we have a clear answer and shouldn't jump to conclusions on either side. I think that work should be done. So-called "isolating" treatments may be equally effective in some cases and I'm not opposed to it if/when research demonstrates it works just as well. I suspect the final answer will be quite complex (individual x diagnosis x severity x motivation x etc.). I also don't think we should be shy about using these treatments as an initial low-intensity intervention (ala primary care). Everyone loves their mildly anxious long-term therapy patient who comes in as scheduled and is quite pleasant, but perhaps that patient is equally well-served by a mindfulness app and doing so would free up that slot for the person with severe depression, alcohol dependence and a history of NSSI with intermittent attempts. If the app works just as well for Patient A...we should use it.

 

[brain hugger]

Fair enough, though that is ultimately an empirical question. I don't think we have a clear answer and shouldn't jump to conclusions on either side. I think that work should be done. So-called "isolating" treatments may be equally effective in some cases and I'm not opposed to it if/when research demonstrates it works just as well. I suspect the final answer will be quite complex (individual x diagnosis x severity x motivation x etc.). I also don't think we should be shy about using these treatments as an initial low-intensity intervention (ala primary care). Everyone loves their mildly anxious long-term therapy patient who comes in as scheduled and is quite pleasant, but perhaps that patient is equally well-served by a mindfulness app and doing so would free up that slot for the person with severe depression, alcohol dependence and a history of NSSI with intermittent attempts. If the app works just as well for Patient A...we should use it.

I agree that the answer is complex (in terms of what will work for which pt, at which time, at which severity, in which context, etc.) and reading it back, I realized that the word "isolating" sounds negative. Maybe a better word is that these approaches pull more towards self-sufficiency? I think that part of what frustrates me is that, within our current society, which I feel is trickling down into our field, is that there's this greater admiration for self-sufficiency and a minimization of our relational needs. Both are highly important (although I recognize my own bias towards the relational) and it's the minimizing of the latter that frustrates me.

 

[smalltownpsych]

Fair enough, though that is ultimately an empirical question. I don't think we have a clear answer and shouldn't jump to conclusions on either side. I think that work should be done. So-called "isolating" treatments may be equally effective in some cases and I'm not opposed to it if/when research demonstrates it works just as well. I suspect the final answer will be quite complex (individual x diagnosis x severity x motivation x etc.). I also don't think we should be shy about using these treatments as an initial low-intensity intervention (ala primary care). Everyone loves their mildly anxious long-term therapy patient who comes in as scheduled and is quite pleasant, but perhaps that patient is equally well-served by a mindfulness app and doing so would free up that slot for the person with severe depression, alcohol dependence and a history of NSSI with intermittent attempts. If the app works just as well for Patient A...we should use it.

I hate this concept of the neurotic long-term easy-to-work with patient. I think that is more of a Woody Allen movie stereotype than what I see in real clinical practice. In my experience, patients self-select. If they are not benefiting in some way they stop coming. Also, I can't keep slots open for ETOH dependence patients, it is actually quite the opposite. These patients are notorious for not showing up. Nothing worse than having my motivated patients not be able to get into see me because my schedule got filled up with people with addiction issues who are notoriously non-compliant.

 

[Ollie123]

I hate this concept of the neurotic long-term easy-to-work with patient. I think that is more of a Woody Allen movie stereotype than what I see in real clinical practice. In my experience, patients self-select. If they are not benefiting in some way they stop coming. Also, I can't keep slots open for ETOH dependence patients, it is actually quite the opposite. These patients are notorious for not showing up. Nothing worse than having my motivated patients not be able to get into see me because my schedule got filled up with people with addiction issues who are notoriously non-compliant.

Really? I see plenty now, though do my best to usher them out the door quickly. Likely setting dependent - my current clinic trends higher in SES and lower in severity than most other settings I've worked in so I'm seeing more mild-moderate adjustment disorder. CMHC forensic clinic...less so. My previous example was just that, so feel free to excise the ETOH dependence from it if you like.

Regardless, my point is just that there are plenty of people out there for whom intensive treatments may not be necessary. We should have lighter-touch interventions than 45 minutes 1x/week. And we should still offer 45 minutes 1x/week treatment. Who gets what and when should depend on the research, not on what has historically been done, our own biases, fears of losing money or greed on behalf of employers/hospitals.

 

[foreverbull]

I agree that the answer is complex (in terms of what will work for which pt, at which time, at which severity, in which context, etc.) and reading it back, I realized that the word "isolating" sounds negative. Maybe a better word is that these approaches pull more towards self-sufficiency? I think that part of what frustrates me is that, within our current society, which I feel is trickling down into our field, is that there's this greater admiration for self-sufficiency and a minimization of our relational needs. Both are highly important (although I recognize my own bias towards the relational) and it's the minimizing of the latter that frustrates me.

I hear you. I also wonder if you also might be getting at a concern of further stigmatization of seeking help from therapists rather than "toughing it out" on your own and reinforcing that archaic notion?

I agree that people do often downplay the importance of the therapy relationship itself as a catalyst for change; and on the flipside, I also think a fair number of people with low-level issues can be helped by doing their own self-help practices independently (as I was saying in my earlier post. I wasn't intending to say that most/all people don't need therapy). I don't want to to minimize the effect of either client or therapist; this is such a complicated topic. So many factors play into the success of therapy, including client-related factors, relationship-related factors, and therapist-specific factors, so it's hard to parse it all out into mutually exclusive percentages and numbers. But agreed, building a strong alliance (i.e. the relationship) is very important, based on what we are able to gather research-wise, and it makes logical sense because we are gregarious beings who benefit from social contact...but it has to be the right fit, which is the tricky part!

 

[brain hugger]

I hear you. I also wonder if you also might be getting at a concern of further stigmatization of seeking help from therapists rather than "toughing it out" on your own and reinforcing that archaic notion?

I agree that people do often downplay the importance of the therapy relationship itself as a catalyst for change; and on the flipside, I also think a fair number of people with low-level issues can be helped by doing their own self-help practices independently (as I was saying in my earlier post. I wasn't intending to say that most/all people don't need therapy). I don't want to to minimize the effect of either client or therapist; this is such a complicated topic. So many factors play into the success of therapy, including client-related factors, relationship-related factors, and therapist-specific factors, so it's hard to parse it all out into mutually exclusive percentages and numbers. But agreed, building a strong alliance (i.e. the relationship) is very important, based on what we are able to gather research-wise, and it makes logical sense because we are gregarious beings who benefit from social contact...but it has to be the right fit, which is the tricky part!

I agree. I think that, for some cases, self-help approaches are the most efficient and effective way of engaging in MH tx. And, for other cases, more is needed. I think what I'm struggling with, like you said, is the downplaying of the importance of the therapeutic relationship (while it may not be important for some, it could be critical for others).

Also, I shared my bias towards relational approaches to help explain why I may have had a stronger reaction to this article. I understand that our biases shouldn't affect our work and, if someone is struggling with a non-relational issue, I wouldn't force/emphasize relational work.

 

[foreverbull]

I agree. I think that, for some cases, self-help approaches are the most efficient and effective way of engaging in MH tx. And, for other cases, more is needed. I think what I'm struggling with, like you said, is the downplaying of the importance of the therapeutic relationship (while it may not be important for some, it could be critical for others).

Also, I shared my bias towards relational approaches to help explain why I may have had a stronger reaction to this article. I understand that our biases shouldn't affect our work and, if someone is struggling with a non-relational issue, I wouldn't force/emphasize relational work.

For sure. I'm a fan of interpersonal approaches! They've definitely deepened my practice.