Cognitive-behavioural therapy (CBT) emerged in the 1970s and ’80s as an imperfect amalgam of cognitive and behavioural therapy, and is by its very nature a changing entity. Today it means something very different than it did a generation ago. Alongside the development of CBT has been the change in self-help books that use CBT principles. Books concerned with the treatment of anxiety are a prime example of this evolution. There is now a huge range of self-help materials to choose from, and both service users and professionals can find the choice over-whelming. Here I select some of the more pertinent, popular and helpful publications. First I describe some data from service users which provide their perspective, then I describe the properties of a good self-help guide and give some examples. I end with recommendations for further relevant self-help resources.
I contacted No Panic, an organisation for people with anxiety problems, to ask for feedback from members on self-help guides for anxiety. They were asked to list the books they had used, describe their good and bad points, and to rate several statements that reflected attitudes towards self-help guides. Eleven members of the organisation completed the exercise. Clearly with such a small sample size, their responses might not be indicative of the population as a whole, but they provide initial insights into the perception of self-help materials by people with anxiety disorders.
What was first evident from this small study was the number of guides that were mentioned - 24 in total. Only a few books were cited by more than one person, whereas an assorted range of diverse books were only encountered by one person each. The three most commonly read books in this sample were Simple, Effective Treatment of Agoraphobia (1977, 1995) and Self-Help for Your Nerves (1962, 1995), both by Claire Weekes and Feel the Fear and Do It Anyway! by Susan Jeffers (1988, 2007). Claire Weekes’ books have clearly stood the test of time as they received almost exclusively positive comments from readers who described her as an experienced, compassionate and helpful writer, although some expressed a reservation that her style was somewhat out of date. Susan Jeffers’ book was also positively received in general, but some found the style to be too eager, with often unrealistic examples targeted towards an American audience. Some of the assorted ‘gems’ cited by individuals received glowing reviews. Examples were Beyond Fear by Dorothy Rowe (2002), Fears, Phobias and Panic by Maureen Sheehan and In Stillness Conquer Fear by Pauline McKinnon (1987, 2000). The books that received negative comments in this survey tended to be the more academic self-help books that were regarded as too distant and included unnecessary information, for example Living with Fear by Isaac Marks (1978, 2005).
From the survey it was possible to identify the key positive and negative properties of self-help guides (Box 1).
Box 1. Positive and negative points of self-help guides
Easy to read
Really understands with compassion
Encouraging and optimistic
Up-to-date information and style
Explained why avoidance makes things worse
Section on building assertiveness
Practical steps provided
Helps me understand myself
Helps me realise I am not going mad
Author identifies with the reader as a normal human being
Can easily ‘dip in’
Helps me to soothe myself
Includes real vignettes or interviews
Author has been through anxiety
Useful medical information
Patronising, impersonal or distant
Only applies to a small range of anxieties
Goals for the reader are not relevant to me
Too much irrelevant information
Need to already be on the road to recovery for this to be helpful
Dwells on the symptoms so much that I imagine that I have them
Not personalised to my difficulties
Unconvincing case examples
The statements on attitudes towards self-help guides also shed light on the readers’ approach to these books. In order to analyse responses, a rating of 50% or more was counted as an endorsement of the statement. Of the 11 readers, 9 believed that ‘No self-help guides are perfect, but I can gain something new form each one that I read.’ Nevertheless, 6 of those surveyed endorsed the statement ‘I am on the look-out for a self-help guide that will provide me with the perfect answer to all my problems’. This shows a mixed pattern of expectations of what a self-help guide can offer. Consistent with the professional view of the role of self-help guides, 9 people endorsed the belief that ‘The most important thing about a self-help guide is seeing it through and putting into practice what it says’, which is encouraging. Nevertheless, there were concerns about real barriers to change. Four of the readers stated that ‘If I were to recover after using a self-help guide, people close to me would not be able to cope with the change.’ Six stated that ‘Self-help guides are always going to be directed at the average person with a phobia, so they could never help me with my very specific, personal problems’. This represents a key dilemma in producing a self-help book - how to present general principles yet maintain a personalised approach. Overall, these statements seem to reflect an acknowledgement of the limitations of a self-help book while maintaining hope that new information can be found and used to further aid recovery.
The feedback from the survey indicates that good self-help books have some of the qualities that one would expect from a good cognitive-behavioural therapist - compassion, accessibility, increasing understanding, and providing practical, realistic steps to help face fears. It may be helpful at this stage to state the principles of contemporary CBT to clarify this convergence. It is worth noting that contemporary CBT is now both broader in scope, incorporating humanistic principles and close integration with basic biology, and more detailed in its application, targeting key cognitive processes that maintain anxiety. Yet, in essence CBT still has the same guiding principles, which, arguably, any good self-help guide would follow.
Clinical anxiety is on a continuum with the ‘normal anxiety’ that all of us have experienced.
The origins of anxiety disorders are not simple and they vary widely between individuals. Yet, they can be understood when considering a person’s temperament, their culture and their life experiences.
Although health professionals can provide information and support, it is the individual’s own responsibility to change - thus, even one-to-one CBT could be considered as a form of ‘self-help’.
The sources of a person’s fear can be faced gradually by breaking them down into manageable ‘chunks’ - the essence of ‘graded exposure’.
When a person faces their fears, it is important that they focus on their experience. Today this is often described as a ‘mindful’ approach - the person is encouraged not to try to control their feelings and thoughts, but to face the experience as it is, in the here and now, in the present without trying to control it. In this way, the individual can acutely perceive what is going on, and then update their beliefs about what is dangerous, and gain increased confidence in the process.
It is becoming increasingly evident that people with anxiety disorders, just like those with depression, have an ‘inner dialogue’ or tendency for ‘recurrent thinking’ that is very negative and undermining towards themselves, sapping away their confidence to face their fears. Learning to notice this tendency and replacing it with more compassionate ways of ‘talking to oneself’ seem to be very important in the long term.
Recent useful self-help books
In my opinion, there are only certain published books that have all, or most, of the above qualities. In addition to the popular books by Claire Weekes and Susan Jeffers, described earlier, I would recommend the following recent guides:
Bemis, J., & Barrada, A. (1994) Embrace the Fear: Learning to Manage Anxiety and Panic Attacks. Hazelden. This book provides a good combination of personalised accounts and plans for action. It also emphasises the ‘inner dialogue’, helping people to build up more ‘ self-nurturing’ ways of thinking.
Kennerley, H. (1997) Overcoming Anxiety: A Self-Help Guide Using Cognitive Behavioural Techniques. Robinson. This is probably the most representative of CBT as it is generally practised in the treatment of anxiety disorders, and includes many useful tables, charts, diagrams and explanations.
Leahy, R. (2006) The Worry Cure: Seven Steps to Stop Worry from Stopping You. Piatkus Books. This book sounds more ‘gung-ho’ than it really is - written by a leading American advocate of CBT, it provides a comprehensive coverage of the most recent cognitive-behavioural approaches to anxiety.
Kabat-Zinn, J. & Brantley, J. (2003) Calming Your Anxious Mind: How Mindfulness and Compassion Can Free You from Anxiety, Fear and Panic. New Harbinger Publications. This is clearly a more‘new-wave’CBT book that focuses on strategies of mindfulness and building up compassionate self-dialogue.
Cartwright-Hatton, S. (2006) Coping with an Anxious or Depressed Child. Oneworld Publications. This book provides an up-to-date approach to helping parents of anxious children. Often, both parent and child can both learn to cope better with anxiety by learning how to face very simple childhood anxieties.
It can be difficult to recommend the ‘right’ book to patients when so many tomes are on offer. Some, such as Claire Weekes’ Hope and Help for Your Nerves and Passing Through Panic, are available as audiotapes, which some people will prefer. The important thing is probably not the exact book, but getting the patient started on self-help in the right way. It was evident from the survey that most people expected to draw self-help information from multiple sources. At the start they can begin to realise that there is a way that they can cope better with their anxiety and start to overcome its impact on their lives. This approach needs to be tempered by an awareness that it may take time, and will need to be under the patient’s own control.
Further self-help resources
What a self-help book does not provide is the capacity to listen and understand in a respectful and thoughtful way - before action comes understanding. For many people, it is their search for this experience that is most difficult. Clearly, any mental health professional can provide this to the best of their ability and resources, but further improvement may need to come from either one-to-one therapy or from the more established organisations and service user groups. There are many sources of help and information of this kind, as any internet search will reveal. However, some of the highest quality sources are given below.
http://psychology.iop.kcl.ac.uk/cadat is the website for the Centre for Anxiety Disorders and Trauma which was pioneered by Professors David M. Clark, Anke Ehlers and Paul Salkovskis. It provides information on anxiety disorders and phobias and sources of support and therapy. The centre regularly conducts controlled trials that may be suitable for patients with certain anxiety disorders.
http://www.fearfighter.com is the website for Fear Fighter, an online site for computer-assisted cognitive therapy.
http://www.babcp.com is the website of the British Association for Behavioural and Cognitive Psychotherapies, which is responsible for accrediting CBT courses and practitioners. It also provides information leaflets and a ‘find a therapist’ page.
http://www.nopanic.org.uk is the website of No Panic, a service users’ organisation. The site includes a great deal of information as well as offering telephone-assisted therapy and a well-designed CBT treatment pack.
http://www.phobics-society.org.uk is the website of the National Phobics Society which provides direct service user support and information.
The provision of online self-help materials is an exciting advance and these materials are likely to develop into more advanced and popular formats in the future. The evidence base is emerging that they can be a successful, cost-effective medium for delivering treatment. However, use of the internet and television programmes are likely to have a more widespread positive effect on our cultural attitudes to anxiety, and the mental health profession will need to adapt as service users become increasingly vocal and empowered.
I thank members of No Panic for their contributions to the survey described in this article.
- © 2007 Royal College of Psychiatrists