Outcomes of Self-help Efforts in Anxiety Disorders

Amy J Morgan; Anthony F Jorm


Expert Rev Pharmacoeconomics Outcomes Res. 2009;9(5):445-459. 

In This Article

Expert Commentary

This review indicates that self-help, as broadly defined by the general public, is not considered an important focus for research. This is partly because many self-help interventions valued by the public, such as positive social support, are not amenable to RCTs. These may require the use of other methodologies to evaluate effectiveness, such as expert consensus (see [12]) or direct consumer ratings of perceived effectiveness when used under real-life conditions (see [83,84]). However, based on RCTs, bibliotherapy and computer or internet CBT interventions are considered potentially useful self-help, and the evidence is accumulating for their effectiveness. Some clinicians and researchers have called for their wider implementation in the healthcare system, such as in stepped-care models, where they could provide a low-cost, nonintrusive, first-line treatment, followed by more intensive interventions if they are unsuccessful.[9] The advantages of a stepped-care approach incorporating guided self-help is predicated on the assumptions that: they reduce costs and enable therapists to see more patients; they are potentially effective (especially for those with milder presentations and sufficient motivation); and patients find them an acceptable alternative to waiting for care. Apart from the financial incentive and reducing unmet need for treatment, self-help materials encourage empowerment and self-control over an individual's problem, enable individuals to set their own pace of treatment, save individuals time and expense traveling to therapy appointments, and are particularly useful for those who feel stigmatized seeking therapy or those who are reluctant to share sensitive and private information with others.[85] Self-help materials also have advantages when applied outside a stepped-care model, in an unguided form. They can improve access to psychological treatments for those with limited access, including prisoners or those in rural communities, and those for whom seeking help is complicated by their disorder, such as people with social anxiety disorder who avoid contact with others.[62]

However, a stepped-care approach incorporating self-help materials has yet to be implemented widely, and may encounter resistance from healthcare practitioners who may feel that self-help materials should not be provided as an independent intervention but should only complement therapy.[86] Self-help materials have a number of other disadvantages. They do not work for everyone and there are large drop-outs from treatment, but, as yet, we cannot predict who they will and will not benefit. Not everyone has the capacity or desire to engage in self-help materials, for instance a reasonable level of literacy or access to technology is required, and few materials are available for specific cultural groups. The majority of the self-help books for anxiety on the market have not been evaluated scientifically, and practitioners may be uneasy recommending or providing one of these books to their patients. Until scientific evidence of efficacy is obtained, expert consensus on helpfulness may be the only alternative.[56,87] Ellis argues that publishers are unlikely to pretest books they plan to publish, as they have few incentives to do so, and it will be up to the authors and other researchers to conduct research on self-help materials.[85] Even with evidence from RCTs, some may question the generalization of results when treatments are used under non-trial conditions, as the absence of trial procedures, such as assessments and compliance checks, may attenuate efficacy.[60]

When used outside professional supervision, even less is known regarding the effects of self-help. As noted previously, 'pure', unguided self-help has not been evaluated, and it is not possible to evaluate in an RCT. However, some argue that this situation is not much different from the efficacy–effectiveness debate on therapist-delivered treatments, where treatment efficacy is established under research conditions not reflective of typical therapeutic contexts.[88] The main disadvantage of unguided self-help materials is the distinct possibility of the individual failing to complete the program, not improving, or even getting worse. This could lead to feelings of failure, disappointment and helplessness. Some have also argued (although it has not been empirically demonstrated) that those who do not succeed at self-help materials may not seek professional psychological treatment because they think it is similar to what they have already tried, and, hence, will not work for them.[9] Self-help books for anxiety cannot provide a thorough assessment and diagnosis, and as some symptoms of anxiety can be caused by physical disorders, individuals may be treating themselves for the wrong problem. Self-help materials also typically focus on one problem at a time, and are not as nuanced in their approach to the individual and their problem, unlike a therapist who can adapt their approach and respond to other problems as they arise.


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