Bibliotherapy/"Self-help" treatment?

[futureapppsy2]

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(I know it's against SDN policy to ask for or give clinical advice, but I'm hoping a clinical discussion post doesn't cross that line. If it does, feel free to delete, T4C).

Hi all,

I'd be curious to hear your thoughts on the effectiveness/ethics bibliotherapy self-help therapy (specifically CBT). In general, the sense I'm getting from the literature is that it can be significantly effective for anxiety/depression, but there are some fairly significant caveats to that, mainly:

1) bibliotherapy/self-help treatment conditions almost always still involved some degree of therapist "support" throughout (though I did find a study where there was no therapist support/interaction except for the intake and follow-up).

2) it seems to loose a good deal of its effectiveness when you get above mild/low moderate symptomatology/severity.

3) it's not often directly compared to in-person CBT but the bibliotherapy results are compared to CBT results from previous RCTs.

4) Most participants in these studies have a history of some prior treatment (usually psychopharmocological treatment; some screen for prior CBT experience), and many are currently taking relevant medication during the intervention period.

Given that online therapy and teletherapy are often viewed skeptically from both quality and ethics POVs, I could see where bibliotherapy could raise some serious redflags, especially as it is often sold directly to the (untrained) public as "do it yourself" treatment. OTOH, it does have some empirical support (albeit perhaps not with the exact same populations or safeguards and treatment parameters as with those who may be buying/using it independently), and thus it might be a good resource for good for subclinical/mild issues issues, especially for people who wouldn't seek in-person treatment but would be open to bibliotherapy/self-help therapy.

Your thoughts?

 

[docma]

In the context of traditional therapy, I think "psychoeducation" is always a key element and takes many forms. When you've assessed a client as ready and able to make use of resources your recommend (or that they discover on their own and find helpful), then "bibliotherapy" makes a great deal of sense. It often is very supportive because it "normalizes" their experience of their condition and, if it is a good resource, provides non-judgmental language for describing ways to manage situation/symptoms--and helps them generalize what they are learning in therapy to everyday life. I do think "bibliotherapy" is a bit pretentious/psychobabbly on the part of our profession.... as "recommended reading" might work just as well.....but whatever works is good.

 

[HopefulStudent8]

The problem that I've seen with self-help is that many (the majority?) of the materials in circulation have absolutely no data about the particular book's effectiveness. Although a book claims to be CBT oriented, that doesn't necessarily mean that the material follows closely to the theory. In addition, and as you mentioned, just because CBT is effective for a particular condition doesn't mean self-help CBT is equally effective. Folks from Drexel have published in this topic. In a review of 50 self-help books, they found that in general, the good books are pretty good in most of the areas that they studied ("overall usefulness, grounding in psychological science, the extent to which it offers reasonable expectations, the extent to which it offers specific guidance for implementing the self-help techniques and for monitoring treatment progress, and whether it offers potentially harmful advice"), but the bad books are REALLY bad in a lot of the areas. The article I found from them is:

Redding, R., Herbert, J.D., Forman, E.M. & Guadiano, B. (2008). Popular self-help books for anxiety, depression and trauma: How scientifically grounded and useful are they? Professional Psychology: Research and Practice, 39, 537-545.

 

[JockNerd]

I think a major problem is that useful books with potential to help (e.g., Ellis' work) might be sitting next to some ridiculous book about magical thinking (e.g., "the secret") that only facilitates problems. And, the fluff books usually prescribe magic that doesn't involve actual work, so which one of those will be more appealing to most folks is pretty obvious.

I think good books (e.g., How to stubbornly refuse to make yourself miserable about anything, yes, anything) can be super beneficial for low-level problems or adjunctive for more severe things.

 

[justme08]

I'm a volunteer in an inpatient psych hospital outside the parameters of your query. I started a group that has actually made a noticeable difference with consumers/patients that involves reading poems and song lyrics and discussing them. If I either had more time or less people in the group I could see how this could be even more effective. It helps guage how they are doing, how they are interpreting things, what's on their mind, etc. Plus, they enjoy the group and look forward to it each week. They have a lot of control in this group compared to most; i.e., they pick their songs (I bring in the lyrics they requested the following week), they read them out loud, and everyone's input is welcomed and not put down, so it's been a good enviroment.

I think using books, poems, and movies can be a good way to provide access to emotions, situtions, etc. But, yeah, that's a very small N I'm basing this opinion on.

 

[futureapppsy2]

I'm a volunteer in an inpatient psych hospital outside the parameters of your query. I started a group that has actually made a noticeable difference with consumers/patients that involves reading poems and song lyrics and discussing them. If I either had more time or less people in the group I could see how this could be even more effective. It helps guage how they are doing, how they are interpreting things, what's on their mind, etc. Plus, they enjoy the group and look forward to it each week. They have a lot of control in this group compared to most; i.e., they pick their songs (I bring in the lyrics they requested the following week), they read them out loud, and everyone's input is welcomed and not put down, so it's been a good enviroment.

I think using books, poems, and movies can be a good way to provide access to emotions, situtions, etc. But, yeah, that's a very small N I'm basing this opinion on.

I think we may be taking about two different things here---apologies for any confusion. I was referring more "book/workbook contained therapy"--basically, a somewhat watered-down tx manual aimed directly to the client (e.g., the Anxiety Workbook, the OCD Workbook, the Bulimia Workbook, etc), not the use of books in therapy, per se.

I get the sense from the posters here that bibliotherapy is more accepted as an adjunct--not a substitute for--traditional therapy, and I'm curious about the opinion surrounding using it as a stand alone tx modality for clinical (as opposed to subclinical) symptoms/disorders. JN and HS8, thanks for bringing up the possibility of harm through the sketchier self-help titles and also that those titles may appeal more to your average shopper, which leads into some ethical quandaries of its own, I think, at least about the ethics of marketing directly to would-be clients with no sort of peer reviewing or empirical grounding (and yes, I know that isn't a) new or b) going away anytime soon.

I found an interesting article on stepped care for OCD, which started with standalone bibilotherapy and then progressed in intensity if the participants didn't show adequate improvement with one level of therapy. After standalone bibliotherapy, the participants were then offered therapist-guided bibliotherapy, and if they failed to respond to that, they were offered traditional CBT. It was a very small n (11, with one early drop-out), but interestingly, the authors found that even though only 2 in 10 participants showed adequate response to the self-administered biblotherapy, few gains (a very small effect size) were made in Step 2 (therapist-supported bibliotherapy), though it did push to of them over the responder "thershold" for the study, suggesting that response to non-novel bibliotherapy wasn't really increased by adding in supportive clinician contact, i.e., it bibliotherapy worked for a client or not wasn't really influenced by added, non-CBT therapist contact. However, the largest effect size by far was still for traditional CBT/ERP. It'd be interesting to see full RCT of this and/or a side-by-side trial of non-therapist-supported bibliotherapy, therapist-supported bibliotherapy, and traditional CBT

Reference:

Tolin, D. F., Diefenbach, G. J., Maltby, N., & Hannan, S. E. (2005). Stepped care for
obsessive-compulsive disorder: A pilot study. Cognitive and Behavioral Practice, 12(4), 403-414

 

[Ollie123]

My views on them are actually relatively simple.

In summary: Study them. If they work, great, have at it. If they don't work, stop using them. If they cause harm...REALLY, STOP USING THEM.

We've done some work in the lab on self-help (not me personally, but others in my vicinity). The public health implications are profound, so even if they are less effective overall than full-blown treatment (I imagine they nearly always are, at least when compared to actual proven treatments) they can be very important in terms of reach and cost effectiveness (two often-neglected public health concepts). If we can "treat" 100,000 people in the time it would take to treat 100, and do it for less money, which effect is stronger isn't quite as important.

That of course, doesn't mean that you stop providing the more effective treatments. I do like the idea of a stepped care approach (though with such a small n I'm not sure that article is the best example).

 

[Therapist4Chnge]

1) bibliotherapy/self-help treatment conditions almost always still involved some degree of therapist "support" throughout

I think books can be helpful adjunctively, though I am far less supportive if they are the primary intervention.

2) it seems to loose a good deal of its effectiveness when you get above mild/low moderate symptomatology/severity.

Severity negatively effects most every intervention, though self-help books can often prey on the more severe individuals because "traditional" approaches have failed. I find this particularly problematic because consumers typically know very little about efficacy and cannot adequately differentiate between quackery and actual supported interventions.

Most "self-help" type books lack ANY empirical support, while a few have some loosely related data pulled from other places. I was approached through a former colleague to ghost-write/consult on the first book of a planned series of "self-help" books, but the publisher was unwilling to make significant changes to the manuscript, and I was unwilling to associate myself with something so "fluffy" and unsubstantiated. The vast majority of those books are made to make money and not actually help someone.

If someone were to read an outline of a self-help book, there may be some common factors worth considering, but the implementation of the information is where they fall short. A professional is needed to do it right because people cannot be reduced down to a few talking points....which is a mistake many non-professionals (and some professionals) make about CBT and related orientations. It is one thing to read the information, but it is a far different thing to implement the information effectively.