© 2003 The Royal College of Psychiatrists
© 2003 The Royal College of Psychiatrists
Reading about self-help books on obsessive-compulsive and anxiety disorders - a review
Institute of Psychiatry, chelsham House,The Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX
Many treatment manuals were originally introduced for research purposes in psychotherapy to standardise treatment programmes among researchers. On the tail of these treatment manuals came the development of self-help manuals for patients. An example is Barlow & Craske's (1994) self-help publication for anxiety and panic, which was born out of their therapist manual.
The profession has not wholly welcomed the development of self-help manuals for clients. In their favour, such publications increase people's insight into their condition, empower them to take more responsibility for their treatment and give them material to show friends and relatives, helping to provide a more supportive social context for change. They also give access to methods of improvement for people not wishing to bring their anxiety disorder to the attention of professional services. When used in conjunction with treatment guided by a therapist, self-help publications can be read in advance of therapy and at the end of therapy to consolidate gains. Used under professional guidance, manuals also act as an aide to training for the therapist, enabling a consistent standard of therapy to be maintained.
There are, however, concerns and arguments against such publications. Wolpe (1977) objected to patients with phobia being treated with the same standard technique and highlighted that phobias can have different causes that require different therapeutic approaches. A further argument against self-help therapies is the lack of the reinforcing positive feedback and motivation that a therapist can offer. Ghosh et al (1988) found patients with phobia who bought a self-help book, then failed to take its self-help exposure advice until, as part of a randomised controlled trial, a psychiatrist asked them to follow it and then return to be rated.
Self-help manuals for anxiety and obsessive-compulsive disorders (OCDs) are largely based on empirically-validated cognitive-behavioural techniques, but very few controlled studies have looked at the efficacy of self-help literature for anxiety and OCDs. Those publications with proven efficacy are therefore high on the shopping list.
In a series of controlled studies, White (1995, 1998) has shown that ‘Stresspac’ a self-help cognitive-behavioural therapy package for individuals with anxiety disorders (White, 1997) produced clinically significant improvement in 67% of the participants at post-therapy, 89% at 1-year and 78% at 3-year follow-up. Ghosh et al (1988) showed that behavioural therapy delivered via a book, Living with Fear (Marks, 1978), was as effective as therapist-guided behavioural therapy. Eighty-four patients with chronic phobia were randomly assigned to self-exposure in vivo, instructed by a psychiatrist, a computer or the book. All three groups had shown significant, similar improvement on all study outcome measures after therapy and at 6 months. Pilot work has shown promising results for the Mental Health Foundation's publication, Managing Anxiety and Depression - A Self-Help Guide (Holdsworth & Paxton, 1999) and a controlled trial is in progress.
An important aspect of a self-help publication is whether it offers accurate information to the reader on the nature of his or her condition and provides good clinical examples with which the reader can identify. Publications by De Silva & Rachman (1999) and Rachman & De Silva (1998) on panic disorder and OCD offer in-depth and up-to-date information, with many clinical examples. These publications stress the importance of an initial assessment by a professional but offer a chapter on self-help therapy.
Greist et al's (1986) publication, Anxiety and its Treatment offers an authoritative overview of anxiety disorders and treatment alternatives and has a well-structured chapter on self-help therapy, guiding readers through a clear series of questions to see if self-help behaviour therapy is appropriate for their needs. This self-help treatment chapter has been taken from Marks' (1978) publication, Living with Fear. The book offers a comprehensive overview of anxiety disorders, including many clinical vignettes with which people will identify.
Getting Control - Overcoming your Obsessions and Compulsions (Baer, 1991) offers a readable and informative section on the clinical aspects of OCD and then cleverly guides the reader into a chapter that assesses his or her obsessive-compulsive symptoms and their severity. With this information, the reader is taken through self-help behaviour therapy and is able to tailor the therapy to his or her needs. The book also has a useful chapter for ‘family, friends and helpers’.
The Overcoming series of publications on panic (Silove & Manicavasagar, 1997), anxiety (Kennerley, 1997), traumatic stress (Herbert & Wetmore, 1999), and social anxiety and shyness (Butler, 1999) all offer readable, accurate information on each of the disorders they cover. All publications in the series offer cognitive and behavioural techniques to overcome problems. Herbert and Wetmore (1999) state that their book ‘is not intended as a replacement for therapy, and may even encourage you to seek out some specialist help’ and it offers invaluable information for both sufferer and therapist. Silove and Manicavasagar (1997) seek to identify those clients for whom self-help therapy is appropriate and those who would need to seek professional help. They then offer advice on the use of behavioural and cognitive techniques for ‘panic’ and ‘in particular’ their publication has two important chapters on preventing setbacks and on troubleshooting. Butler's (1999) publication on ‘social anxiety and shyness’ offers an interesting section on the psychodynamic causes of social shyness and an overview of the disorder. The publication then gives a range of cognitive techniques to overcome the problem. Kennerley's (1997) publication on ‘anxiety’ includes informative, well-structured information on the disorder and cognitive and behavioural techniques to overcome anxiety.
Page (2003) offers a pocket-sized publication, Don't Panic, with a quick, useful explanation of anxiety symptoms and some cognitive and behavioural coping techniques.
This article is not complete without mentioning the next generation of self-help psychotherapies for anxiety and OCD, which will be delivered via adaptive computer-delivered systems. Self-treatment computer systems for anxiety and OCDs vary greatly in the degree to which they take on the therapeutic role, decreasing the need for clinician input (Oakley-Browne & Toole, 1994).
At one end of the spectrum, there are basic aids to therapy to be used by the clinician and patient to aid exposure in phobic anxiety, such as computer video-clips of spiders and virtual reality depictions of height (Hassan, 1992). A few systems are closer to becoming complete self-treatment systems, carrying out most of the therapeutic tasks involved in treatment and decreasing the need for input by a clinician by 80-95%.
In terms of therapeutic outcome, there is evidence to suggest that computer therapy is an acceptable approach in the treatment of anxiety (Carr et al, 1988) and computer-based interviews have been shown to be acceptable to patients (Erdman et al, 1992). There is evidence to support the effectiveness of palmtop computer treatment for panic disorder (Newman et al, 1997), BTSTEPS computerised voice-interactive behaviour therapy, accessed via a touch-tone telephone, for the treatment of OCD (Greist et al, 2002), FEARFIGHTER, a screen-based computer system for the treatment of phobic anxiety disorders (Marks et al, 2003) and Beating the Blues, a screen-based computer system delivering cognitive-behavioural therapy for anxiety and depression (Proudfoot et al, 2003). There are also promising results from uncontrolled studies for computerised cognitive-behavioural therapy for anxiety disorders (Stresspac; White, 2000), anxiety and depression (BALANCE; Yates, 2000; COPE; Osgood-Hynes et al,1998).
Access to self-help for anxiety and for those with OCD is available in a number of formats ranging from websites putting people in contact with local self-help groups and fellow suffers (http://www.triumpoberphobia.com) through to CD-Rom interactive publications. Restoring the Balance, based on BALANCE (Yates, 2000) is available from the Mental Health Foundation (http://www.mentalhealth.org.uk) as a CD-Rom publication. Beating the Blues software is available from Ultrasis Interactive Healthcare (http://www.ultrasis.co.uk). FEARFIGHTER (Marks et al, 2001) (http://www.fearfighter.com) is available via internet access.
As the evidence for the cost-effectiveness of computer therapies increases, there is no doubt that such systems will be used more often in everyday clinical practice. In fact, at the time of going to press, computer-delivered psychotherapies for anxiety disorders are being incorporated into therapy services within a number of NHS trusts.
References
- BAER, L. (1991) Getting Control: Overcoming your Obsessions and Compulsions. Boston: Little Brown & Co.
- BARLOW, D. H. & CRASKE, M. G. (1994) Mastery of your Anxiety and Panic, II. New York: Graywind.
- BUTLER, G. (1999) Overcoming Social Anxiety and Shyness. London: Robinson.
- CARR, A. C., GHOSH, A. & MARKS, I. M. (1988) Computer-supervised exposure treatment for phobias. Canadian Journal of Psychiatry, 33, 112 -117.[Medline]
- DE SILVA, P. & RACHMAN, S. (1999) Obsessive-compulsive Disorder. The Facts. Oxford: Oxford University Press.
- ERDMAN,H.P.,KLEIN,M.H.,GREIST,J.H., et al (1992) A comparison of two computer-administered versions of the NIMH Diagnostic Interview Schedule. Journal of Psychiatric Research, 26, 85-95.[CrossRef][Medline]
- GHOSH, A., MARKS, I. M. & CARR, A. C. (1988)
Therapist contact and outcome of self-exposure treatment for phobias. A
controlled study. British Journal of Psychiatry,
152,
234
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[Abstract/Free Full Text] - GREIST, J. H., JEFFERSON, J.W. & MARKS, I. M. (1986) Anxiety and its Treatment. Help is Available. Washington, DC: American Psychiatric Press.
- GREIST, J. H., MARKS, I. M., BAER, L., et al (2002) Behaviour Therapy for Obsessive Compulsive Disorder Guided by a Computer or by a Clinician Compared with Relaxation as a Control (submitted).
- HASSAN, A. A. M. (1992) Comparison of computer-based symbolic modelling and conventional methods in treatment of spider phobia. Doctoral Dissertation, University of Leeds, England.
- HERBERT, C. & WETMORE, A. (1999) Overcoming Traumatic Stress. London: Robinson.
- HOLDSWORTH, N. & PAXTON, R. (1999) Managing Anxiety & Depression - A Self-help Guide. London: Mental Health Foundation.
- KENNERLEY, H. (1997) Overcoming Anxiety. London: Robinson.
- MARKS, I. M. (1978) Living with Fear. Understanding and Coping with Anxiety. New York: McGraw-Hill International.
- MARKS, I. M., KENWRIGHT, M., McDONOUGH, M., et al (2003) Behaviour therapy for phobic anxiety disorder guided by a computer or by a clinician compared with computer guided relaxation therapy. Psychological Medicine (in press).
- NEWMAN, M. G., KENARD, J., HERMAN, S., et al (1997) Comparison of palmtop-computer-assisted brief cognitive-behavioural treatment to cognitive-behavioural treatment for panic disorder. Journal of Consulting and Clinical Psychology, 65, 178 -183.[CrossRef][Medline]
- OAKLEY-BROWNE, M. A. & TOOLE, S. (1994) Computerised self-care programs for depression and anxiety disorders. In Computers in Mental Health (eds G. Andrews et al). Geneva:World Health Organization/Churchill Livingstone.
- OSGOOD-HYNES, D. J., GREIST, J. H., HENEMAN, S.W., et al (1998) Self-administered psychotherapy for depression using a telephone-accessed computer system plus booklets. Journal of Clinical Psychiatry, 89, 358 -365.
- PAGE, A. (2002) Don't Panic: Overcoming Anxiety, Phobias and Tension (2nd edn). Sydney: Gore & Osmeni.
- PROUDFOOT, J., GOLDBERG, D., MANN, A., et al (2003) Computerized, interactive, multimedia cognitive-behavioural program for anxiety and depression in general practice. Psychological Medicine, 33, 217 -277.[CrossRef][Medline]
- RACHMAN, A. & DE SILVA, P. (1998)Panic Disorder - the Facts. Oxford: Oxford University Press.
- SILOVE, D. & MANICAVASAGAR,V. (1997) Overcoming Panic. London: Robinson.
- WHITE, J. (1995) ‘Stresspac’: A self-help anxiety management package: A controlled outcome study. Behavioural and Cognitive Psychotherapy, 23, 89 -107.
- WHITE, J. (1997) ‘Stresspac’. London: Psychological Corp.
- WHITE, J. (1998) ‘Stresspac’:Three-year follow-up of a controlled trial of self-help package for the anxiety disorders. Behavioural and Cognitive Psychotherapy, 26 , 133-141.
- WHITE, J., JONES, R. & McGARRY, E. (2000) Cognitive-behavioural computer therapy for the anxiety disorders: A pilot study. Journal of Mental Health, 9, 505-516.[CrossRef]
- WOLPE, J. (1977) Inadequate behaviour analysis: the Achilles heel of outcome research in behaviour therapy. Journal of Behaviour Therapy and Experimental Psychiatry, 8, 1-4.
- YATES, F. (2000) Restoring the Balance: a self-help program for managing anxiety and depression (CD-ROM). London: Mental Health Foundation.
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