Handbook of Self-Help Therapies

Patti Lou Watkins, George A. Clum, Patti Lou Watkins, George A. Clum

• Publisher: Routledge
• Year: 2007
• eBook ISBN: 9781135607753
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This volume constitutes the first solidly research-grounded guide for practitioners wending their way through the new maze of self-help approaches. The Handbook of Self-Help Therapies summarizes the current state of our knowledge about what works and what does not, disorder by disorder and modality by modality. Among the covered topics are: self-regulation theory; anxiety disorders; depression; childhood disorders; eating disorders; sexual dysfunctions; insomnia; problem drinking; smoking cessation; dieting and weight loss. Comprehensive in its scope, this systematic, objective assessment of self-help treatments will be invaluable for practitioners, researchers and students in counseling psychology, psychiatry and social work, health psychology, and behavioral medicine.

CHAPTER 1

Self-Help Therapies

Past and Present

PATTI LOU WATKINS

What Is Self-Help?

Definitions of self-help seem as varied as the myriad of programs that use this label to describe their contents. First, it may be useful to distinguish between self-help groups and media-based self-help approaches (Gould & Clum, 1993). According to Den Boer, Wiersma, and Van Den Bosch (2004), each of these has a distinct “history of development, methodology, research strategy, and relationship with professionals” (p. 960). In self-help groups, individuals with a shared problem lend support and assist each other in coping with and/or overcoming the problem in question. Den Boer et al. stress that such groups should not be confused with professionally led support groups, remarking that lay networks represent the oldest system of care for various maladies. Alcoholics Anonymous and its derivatives epitomize contemporary self-help groups. A number of texts (e.g., Kurtz, 1997; Powell, 1994; Riessman & Carroll, 1995) already exist that attempt to summarize the body of knowledge surrounding self-help groups. Thus, the focus of the current text is on media-based self-help, a relatively new means for individuals to manage both medical and psychological problems.

In their meta-analytic review, Gould and Clum (1993) defined media-based self-help as including books, manuals, audiotapes, videotapes, or some combination of these formats. Over the ensuing decade, computer-based self-help programs have proliferated and now must be considered part of the mix of media-based self-help interventions. For instance, Tate and Zabinski (2004) describe the use of Web-based self-help programs as well as the use of handheld computers to deliver treatment strategies that would otherwise have been implemented by a therapist. Some researchers have used the term bibliotherapy as synonymous with media-based self-help. In his meta-analytic review, Marrs (1995) defines bibliotherapy as “the use of written materials or computer programs, or listening/viewing of audio/ videotapes for the purpose of gaining understanding or solving problems relevant to a person’s developmental or therapeutic needs” (p. 846). Because the modality by which an intervention is delivered (e.g., book vs. Internet) may produce disparate results—or may produce similar results albeit via different mechanisms—we prefer to reserve the term bibliotherapy for interventions that are actually delivered in written form. In essence, bibliotherapy is a subset of the broader term, “media-based self-help,” which refers to interventions delivered across the aforementioned modalities. Nevertheless, bibliotherapy—at least for the time being—remains the largest category of media-based self-help. Thus, an examination of the variations within this category seems warranted.

Bibliotherapy

Anderson et al. (2005) assert that, “Self-help is difficult to define but there is consensus that self-help books should aim to guide and encourage the patient to make changes, resulting in improved self-management, rather than just provide information” (p. 387). With similar conviction, Lichterman (1992) defines self-help books as “an enduring, highly popular non-fiction genre” (p. 421). Unfortunately, such consensus is not so easy to come by. A number of scholars would dispute these descriptions, offering a broader definition of self-help books, or bibliotherapy. Campbell and Smith (2003) include both nonfiction and fiction works among self-help books for psychological distress. The former, which correspond to those that Anderson et al. had in mind, typically include specific treatment techniques, often cognitive–behavioral in nature, intended to accomplish certain treatment outcomes. Although the subject of far less research, the latter merits mention in the delineation of bibliotherapy.

Starker (1989) describes a continuum between informational and anecdotal forms of bibliotherapy. At one end of this continuum lie informational sources that are comprised of empirically based directives for behavior. At the other end of the continuum reside anecdotal sources that, instead, rely upon “interesting, amusing, or biographical incidents” (p. 9). Similarly, Riordan, Mullis, and Nuchow (1996) distinguish between didactic and imaginative materials. Didactic bibliotherapy provides suggestions for new behaviors, presumably through specific therapeutic techniques. Imaginative bibliotherapy, on the other hand, incorporates the works of fiction to which Campbell and Smith allude. However, it may also include poetic and other inspirational forms of literature, fiction and nonfiction, that provide insight and understanding to readers. Johnson, Johnson, and Hillman (1997) also describe self-help books as ranging from specific therapeutic procedures to inspirational prose, citing the Bible as perhaps the most long-lived form of motivational bibliotherapy. Sommer (2003) describes the use of autobiographies in overcoming psychological distress. He explains that clients’ identification with someone who has suffered the same problem may prove therapeutically beneficial. Pantalon (1998) concurs, stating that biographies and novels may not have been intended as self-help but that some individuals may find characters’ attempts to cope with similar problems therapeutic in some fashion. As articulated by Riordan et al. (1996), readers of imaginative bibliotherapy “moved from identification with characters and situations through catharsis to the development of insight which applied to their own condition or issues” (p. 170).

While virtually any written material may be construed as bibliotherapy, nonfiction books, manuals, or pamphlets that provide information while prompting decision-making and problem-solving more aptly typify self-help reading (Campbell & Smith, 2003). Pantalon (1998) offers a useful classification of such materials, which includes; (a) general self-help books, (b) problem-focused self-help books, and (c) technique-focused self-help books. In this scheme, general self-help books are those that address broad-spectrum emotional health and relationship issues rather than specific disorders. Such books may provide general guidelines for well-being, but they do not include assessment or treatment exercises in a systematic approach. Women Who Love Too Much (Norwood, 1985) and Awakening At Midlife: A Guide to Reviving Your Spirit, Recreating Your Life, and Returning to Your Truest Self (Brehony, 1996) exemplify this category of books. Starker (1989) might call such offerings descriptive bibliotherapy, in which authors present a number of wide-ranging suggestions that readers may or may not choose to follow.

In contrast, problem-focused self-help books target a particular disorder (e.g., panic attacks, depression, insomnia, etc.), providing “specific techniques and homework exercises within a structured protocol” (Pantalon, 1998, p. 267). According to Anderson et al. (2005), this form of self-help “fits well with cognitive behavioural therapy, in which patients are encouraged to carry out work in between sessions in order to challenge unhelpful thoughts and behaviours” (p. 388). Pantalon concedes that most books of this ilk derive from a cognitive–behavioral perspective, although he states that problem-focused self-help books may also draw from other psychological orientations. In 1978, Glasgow and Rosen noted that self-help books have been based on Gestalt, rational–emotive, transactional analysis, and hypnotic methods of intervention. In the succeeding decades, however, cognitive–behavioral therapies appear to be the predominant means of intervention (Garvin, Striegel-Moore, Kaplan, & Wonderlich, 2001). Examples of problem-focused bibliotherapy abound throughout this text, as this brand of self-help has been the subject of most empirical research in this area. Finally, Pantalon describes technique-focused self-help books as akin to problem-focused manuals. Both include specific therapeutic techniques; however, in the latter case, these intervention strategies could be applied across problem areas. Pantalon cites The Relaxation Response (Benson, 1975), which perhaps best characterizes this form of bibliotherapy. Starker (1989) might describe both problem- and technique-focused manuals as prescriptive bibliotherapy, in which authors mandate readers to follow authoritative rules and directives.

Levels of Contact

In attempting to define self-help, a larger issue looms than determining the modality (i.e., book, audiotape, videotape, computer), the content (e.g., type of technique), or the purpose (e.g., providing inspiration vs. eliminating a target behavior) of the work. This issue involves the amount of contact, if any, an individual should have with others for an intervention to truly be considered “self”-help. The others to be considered in this debate include health care practitioners, significant others, and the community of consumers themselves. The role of health care practitioners in the administration and resultant effectiveness of self-help interventions has received the most attention in the literature to date as illustrated by a recent article entitled “Self-Help and Minimal Contact Therapies for Anxiety Disorders: Is Human Contact Necessary for Therapeutic Efficacy?” (Newman, Ericckson, Przeworski, & Dzus, 2003). Thus, contact with practitioners will serve as a starting point for our discussion.

In reality (i.e., outside the confines of research settings), most self-help materials are purchased and used by individuals independent of contact with a practitioner (Johnson et al., 1997). Pantalon (1998) suggests that this is more likely the case with general self-help books, but that problem-focused self-help books are also oft used by individuals apart from any professional contact. Some authors in the self-help arena voice strong opinions as to the appropriateness of independent self-help usage. For instance, Adams and Pitre (2000) state that bibliotherapy “should never entirely replace the therapist” (p. 645), who is viewed as necessary for a variety of functions, including selection of the material itself, interpretation, and subsequent processing. Lehane (2005) advises that self-help books should be seen as only part of a solution, rather than the entire solution to the whole array of clients’ problems. Riordan et al. (1996) state similar concerns, prompting readers to consider bibliotherapy as a single tool to be used within a broader therapeutic context. They assert that “To conceive of bibliotherapy as using a book to solve problems is deferring to an ‘all or none’ thinking pattern” (p. 178). As such, these authors question whether self-help materials should even be examined in isolation (i.e., apart from therapist contact) in research studies.

Perhaps Riordan et al. need not worry, because when self-help programs have been empirically investigated, some level of practitioner contact inevitably takes place, even though said contact is not intended to be therapeutic (e.g., Watkins, 1999). For purposes of their meta-analytic review, Gould and Clum (1993) defined self-help as media-based materials that “are used largely by an individual independent of a helping professional” (p. 170). Even in their “pure” or “unadulterated” classification of studies, Gould and Clum noted that therapist contact occurred, although for assessment purposes only. Interestingly, these researchers found no difference in effectiveness between this condition and a minimal contact condition in which practitioners interacted briefly to monitor progress, clarify procedures, answer questions, and provide general encouragement. Furthermore, these self-help conditions appeared to be as effective as therapist-assisted interventions in this meta-analysis.

The extent to which therapist contact affects treatment outcome in studies of self-help programs is a question of ongoing empirical research—and one that many of the chapters in this text attempt to answer. One might revisit Glasgow and Rosen’s (1978) seminal writing on self-help interventions to conceptualize this question. In this article, the authors describe four levels of therapist–patient contact. The first level, dubbed self-administered therapy, involves contact solely for assessment purposes. This is synonymous with the condition labeled pure or unadulterated self-help by Gould and Clum (1993). Glasgow and Rosen referred to the second level as minimal contact therapy. This might involve some therapist interaction at the outset to introduce the intervention materials. It may also entail subsequent check-ins, perhaps via telephone, to determine whether clients are enacting the intervention as planned. The third level is known as therapist-administered intervention. Here, the therapist plays some active role such as clarifying or elaborating upon the material contained within the self-help program. However, the onus is still on the client to implement treatment strategies. Facilitated self-help is a term used by Rogers, Oliver, Bower, Lovell, and Richards (2004) to describe this circumstance in which “the patient receives brief assistance from a therapist to help in implementing programmes and activities in the manuals” (p. 41). Glasgow and Rosen’s fourth level of contact is known as therapist-directed intervention. This refers to traditional psychotherapy in which the therapist conducts treatment that does not include use of a self-help program. Conceivably, the first three levels in this model might be construed as self-help, not because the individual acts in isolation but because she/he is primarily responsible for implementing the treatment techniques.

Contact with a practitioner may not be the only manner in which consumers of self-help programs potentially derive therapeutic benefit from the presence of others. Lehane (2005) reports that clients have shared their self-help reading with family members and that such interactions are valuable. Simonds (1992) describes the case of a woman who discussed her self-help reading on relationships with her husband. This discussion subsequently led to a processing of feelings and mutual problem-solving behavior. Watkins (1999) presents a case study in which a woman using a self-help manual for panic disorder also interacted with significant others over the material contained therein. Watkins explains that this manual, Coping with Panic (Clum, 1990), actually includes explicit instruction for readers to adaptively engage with significant others about their symptoms and the treatment strategies that the manual prescribes. In fact, the manual advises readers to view such communication as a form of coping. Researchers have yet to systematically investigate the extent to which consumers of self-help engage with significant others over these programs or the extent to which such interaction may facilitate treatment outcome. As is the case with therapist contact, this remains a subject for ongoing empirical investigation.

Employing qualitative research, Grodin (1991, 1995) examined the ways in which women utilize self-help reading, interviewing participants as to which elements of this process they found beneficial and which they found dissatisfying. Based on these interviews, Grodin (1995) articulates the notion that female readers of self-help literature “construct a community of others with whom to share a sense of purpose and meaning” (p. 130). This community consists of the women whose stories—similar to the readers’ own—are represented as illustrative vignettes within the pages of the books. It may also include other readers of these books who endure the same circumstances. Consistent with this view, Simonds (1992) writes that “Reading about emotions or experiences they had suffered through made women realize that they were not abnormal or alone” (p. 85). Although the others in this scenario reside in the consumer’s imagination, they nevertheless impacted the perceived benefit Grodin’s and Simond’s participants reported. Grodin describes this phenomenon as contrasting to the American therapeutic ideal of autonomy and self-responsibility in which dependence and reliance on others may, in fact, be seen as pathological. Grodin (1991) contends that women’s sense of self “pivots upon a desire for autonomy and a desire for connection to a world beyond the self” (p. 416). Paradoxically, women who read self-help books develop a stronger sense of self, not in isolation but by connecting with their constructed community of others.

In this section, we have touched upon the role that practitioners, significant others, and even imaginal others play in individuals’ use of media-based self-help materials. This suggests that the term self-help may be somewhat of a misnomer in that a variety of people, professionals and non-professionals alike, may influence the effectiveness of these interventions. Similarly, Garvin et al. (2001) state that “The rhetoric of self-help, with its explicit focus on the self, furthers the misconception that self-help only involves the individual” (p. 163). They stress the need to acknowledge the interpersonal aspects of self-help programs, maintaining that the impact of others—therapeutic agents in this case—should remain in the forefront of empirical research. To overlook the potential curative role of the practitioner may constitute a breach of professional standards. While the self may not act in isolation as the term self-help implies, we do not seek to r...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• Contents
• Preface
• About the Editors
• About the Authors
• 1 Self-Help Therapies: Past and Present
• 2 Good Intentions Are Not Enough: Reflections on Past and Future Efforts to Advance Self-Help
• 3 Self-Help Interventions: Mapping the Role of Self-Administered Treatments in Health Care
• 4 Self-Regulation Theory and Self-Help Therapies
• 5 Self-Help Therapies for Anxiety Disorders
• 6 Self-Help Therapies for Depression
• 7 Self-Help Therapies for Childhood Disorders
• 8 Self-Help Therapies for Eating Disorders
• 9 Self-Help Therapies for Sexual Dysfunctions
• 10 Self-Help Therapies for Insomnia
• 11 Self-Help Therapies for Problem Drinking
• 12 Self-Help Therapies for Cigarette Smoking Cessation
• 13 Great Expectations: Self-Help Therapies for Dieting and Weight Loss
• 14 Preventing Weight Gain with Internet Programs
• 15 An Ecological Perspective on Self-Help: The Case of Diabetes
• 16 Self-Administered Therapies in Primary Care
• 17 Self-Help Therapies: Retrospect and Prospect
• Footnotes
• Index