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Behavioural and Cognitive Psychotherapy, 2006, 34, 13–23
Printed in the United Kingdom doi:10.1017/S1352465805002481
Self-Help: Towards the Next Generation
Rachel Richardson and David A. Richards
University of York, UK
Abstract. In the UK, recent guidelines on the treatment of depression and anxiety recommend
CBT-based self-help materials as one important component of services. However, despite being
based on specific CBT techniques or “empirically grounded interventions”, early optimism
has been dented by data from recent studies that have cast doubt on the effectiveness of the
current generation of these materials. As a consequence, it may be necessary to consider that
other factors may contribute to the overall magnitude of CBT effects. Indeed, it is logically
inconsistent to argue that specific factors are pre-eminent in CBT whilst maintaining that
delivery via therapists is more likely to be effective than self-help. The contribution of “common
factors” that operate in personal therapeutic encounters, for example, therapist responsiveness
and the patient-therapist alliance, may be one possible overlooked reason for the reduced ef-
fectiveness of self-help materials. The development of the next generation of self-help
materials, therefore, may benefit from the testing of materials that combine common and
specific factors, including specific measurement of the strength of common factors and their
relationship to clinical outcomes. We discuss a model of such common factors and suggest
how they could be incorporated into the next generation of CBT based self-help materials.
Keywords: Self-help, depression, anxiety, common factors, cognitive behavioural therapy,
NICE.
Background
Self-help as a method of alleviating the distress caused by mental health problems is an
idea that is gaining increasing prominence. Clinical guidelines recently issued by the National
Institute for Health and Clinical Excellence (NICE) recommend the use of self-help techniques
in the treatment of panic disorder, generalized anxiety disorder and mild depression (National
Institute for Clinical Excellence, 2004a, 2004b). This emphasis on self-help is consistent with
other recent policy initiatives: for example, the National Service Framework (NSF) for Mental
Health (Department of Health, 1999) is underpinned by the principles of involving service
users in the delivery of care and of accessibility to services (Lewis et al., 2003). Both of these
principles are extremely relevant to self-help.
However, defining self-help is not without difficulty and is an area of considerable debate.
Depending on one’s viewpoint, self-help definitions can include a collection of highly specific
psychological treatment materials delivered alone or with minimal support (Lewis et al., 2003),
places to go and people to see outside the “official” treatment agencies in order to receive peer
affirmation and support (Rogers and Elliot, 1997), and a series of generic supportive strategies
Reprint requests to Rachel Richardson, Research Fellow, Area 4, Seebohm Rowntree Building, Department of Health
Sciences, University of York, York YO10 5DD, UK. E-mail: cr14@york.ac.uk
© 2006 British Association for Behavioural and Cognitive Psychotherapies
14 R. Richardson and D. A. Richards
for living (Faulkner and Layzell, 2000). According to Lewis et al. (2003), even if self-help
is defined as therapeutic information, it should do more than merely give information and
advice. Its success depends on a dynamic interaction between materials and users so that they
are able to set their own goals, learn relevant skills and understand how to protect against
relapse. Even from a professional’s point of view, therefore, self-help includes elements of
patient empowerment and is regarded by many as a sophisticated intervention in its own right
rather than as merely a cheaper variant of care by professionals (Richards, 2004).
Nonetheless, it would be inappropriate to ignore the need for cost-effective and accessible
forms of mental health care, particularly for the common problems of depression and anxiety.
In England, the recent 5-year review of the NSF for Mental Health acknowledged that the
availability of psychological services has increased (Department of Health, 2004), although
“long waiting lists remain in many places” (p. 72). The review recommended that the National
Institute for Mental Health in England (NIMHE) “explore ways of expanding the availability
of talking treatments”. These would be likely to include “self-help technologies” (p. 72).
Furthermore, patients who are diagnosed with depression and anxiety in primary care are
likely to represent only a proportion of people with these disorders in the wider community
(Goldberg and Huxley, 1980). In a recent survey of adults carried out by the Office for
National Statistics (ONS) about 1 in 6 were assessed as having a neurotic disorder in the
week before interview (164 cases per 1000 adults) (Office for National Statistics, 2001). The
most prevalent was mixed anxiety and depressive disorder, with 88 cases per 1000 adults.
It seems reasonable to argue that if more accessible forms of care were available, more of
this group would access and receive treatment through a greater range of routes, beyond the
traditional GP referral. Given this level of need and the dearth of trained staff to provide
effective psychological therapies, it is clear that the NSF review’s recommendations regarding
the increase in self-help availability should be addressed as a matter of urgency.
Cognitive behavioural therapy and the content of self-help
Cognitive behavioural therapy (CBT) researchers have a half-century-long tradition of revolt
against the notion that psychotherapy is an art that can only be learnt through experiencing
psychotherapy oneself. Equally, in contrast to other therapy models, CBT has rejected the idea
that the central focus and agent of change in psychotherapy should be the relationship between
practitioner and patient. This has led to the development of a set of “empirically grounded
clinical interventions” (Salkovskis, 2002, p. 4), acknowledging the roles of theory, empiricism
and the scientist-practitioner (Barlow, Hayes and Nelson, 1984). CBT has developed through
both “big-” and “small-science”, from single case experimental designs to randomized
controlled trials. Even at the level of individual therapy, Beck and colleagues highlight the
emphasis in CBT on “empirical investigation” involving both the patient and the therapist
(Beck, Rush, Shaw and Emery, 1979, p. 7).
This approach to psychological therapy has furnished the modern cognitive behavioural
therapist with an array of specific techniques and approaches that the scientific method
has shown to be effective. Examples include exposure for phobias, cognitive restructuring
for depression, and cognitive behavioural interventions for people with psychosis. This
emphasis on science has, of course, been fundamental to the success of CBT and has led to
CBT being the most frequently supported evidence-based psychological treatment in clinical
guidelines, the recent NICE guidelines being an example of this (National Institute for Clinical
Self-help 15
Excellence, 2004a, 2004b). CBT researchers and practitioners regard its “specific factors”, i.e.
its “empirically grounded clinical interventions” as the reason for this success. As such, these
specific techniques are generally held to possess their own independent therapeutic agency;
that there is a direct and strong relationship between techniques and patient recovery.
It is precisely because of this belief in the independent agency of specific CBT techniques
that they have been prime candidates for translation into self-help formats. This translation
has been aided by the fact that many of these techniques are very clearly described and
have often been manualized as part of their development and testing. As a consequence,
the majority of current self-help materials have CBT techniques as their main therapeutic
content. Indeed, the NICE evidence-based guidelines on depression and anxiety recommend
CBT-based self-help (National Institute for Clinical Excellence, 2004a, 2004b). Most self-help
manuals and computer-based programmes try to disseminate these specific CBT techniques to
a wide audience of potential patients. They are used during CBT by the majority of therapists
(Keeley, Williams and Shapiro, 2002) and as interventions in their own right (Lovell et al.,
2003; Richards, Lovell and McEvoy, 2003).
However, uncertainty exists over the effectiveness of the current generation of self-help
technologies. Despite early enthusiasm and accompanying optimistic studies (Cuijpers, 1997;
Bowman, 1997), more recent reviews, whilst conceding that the available research generally
concludes that self-help is beneficial, raise concerns over the quality of this research (Bower,
Richards and Lovell, 2001; Lewis et al., 2003; Kaltenthaler, Parry and Beverley, 2004). For
example, Lewis et al. (2003) express doubt as to “whether this evidence is of sufficient rigor
to recommend the use of self-help materials” (p. 99). Given these concerns, one could argue
that this earlier research has given an over optimistic impression of the effectiveness of current
technologies, since it is well acknowledged that “poor trial design makes treatments look better
than they really are” (Moore and McQuay, 2000, p. 1). These concerns have been reinforced
by recent rigorously conducted randomized controlled trials that have been equivocal about
the benefits of self-help (Richards, Barkham et al., 2003; Mead et al., 2005). Despite increased
patient satisfaction, both these studies found no significant clinical advantage for self-help
compared to usual care when guided self-help delivered by practice nurses in primary care
was compared to usual treatment by General Practitioners alone (Richards, Barkham et al.,
2003) or when it was delivered by psychology assistants to patients awaiting psychological
therapy compared to those who remained untreated on the waiting list (Mead et al., 2005).
If the critical reviews of the evidence base, supported by these later studies, are to be
believed, there are a number of candidate variables to account for weaker effects, including
such things as context and setting. We will argue that the therapeutic impact of CBT may
be attributable to more than the application of specific empirically grounded techniques, and
that one potential element that might explain the apparent failure of the current generation of
self-help methods to fulfil their early promise may be the lack of attention paid to “common
factors” present in therapist assisted CBT in the development of self-help materials. It may be
that the effects of self-help can be enhanced by delivering it in a context where such common
factors can contribute to overall effects.
Common factors
As a consequence of the prominence given to techniques or “specific factors”, cognitive
behaviour therapists have traditionally placed less emphasis than other schools on factors
16 R. Richardson and D. A. Richards
common to all types of psychotherapy. However, there is considerable interest and a large body
of research on the so-called “common factors” in psychotherapy, interest that can be traced back
to a seminal paper published in 1936 (Rosenzweig, 1936). Rosenzweig noted that all forms of
psychotherapy achieved successes. He argued, therefore, that there are unrecognized factors
that operate in any therapeutic situation that contribute to the success of the therapy. He further
argued that these unrecognized factors operate in apparently different forms of psychotherapy
and that it is having these in common that makes therapies equally successful. More recently,
researchers have argued that as much as 30% of the improvement in psychotherapy is due to
common factors, in contrast to a supposed 15% contribution that can be attributed to specific
techniques (Lambert and Barley, 2002).
Much of the research on common factors has centred on the therapeutic relationship.
Researchers have defined specific elements of this relationship and examined to what extent
they contribute to therapeutic outcome. A recent extensive review of the literature on this topic
included elements on factors such as empathy and the alliance between therapist and patient
(Norcross, 2002). Common factors were examined to determine how each one correlated with
the outcome of therapy. The authors found strong correlations between certain relationship
elements and therapy outcome: these were the alliance (Horvath and Bedi, 2002), cohesion
in group psychotherapy (Burlingame, Fuhriman and Johnson, 2002), empathy (Bohart, Elliot,
Greenberg and Watson, 2002) and goal consensus and collaboration (Tryon and Winograd,
2002). It is, of course, possible to argue that the case for the therapy relationship having a
causal link to outcome is far from proven. Current research only shows a correlation between
the two and it is difficult to see how research could be designed that would prove a causal link
(Norcross, 2002). Elements of the therapeutic relationship would be difficult to manipulate as
independent variables. However, this body of evidence does warrant consideration in terms of
its general applicability to CBT and its specific role in self-help.
CBT and the therapeutic relationship
In 1979, Beck et al. (p. 45) described the therapeutic relationship as the “context” in which
specific techniques are applied. Twenty-five years later, Goldfried (2004) echoed this view
and described the relationship as “like the anesthesia that allows for a surgical procedure to be
performed” (p. 98). This is in sharp contrast to other schools of psychotherapy that view the
relationship as central to a patient’s recovery. However, recent researchers have suggested that,
even in cognitive therapy, there may be an association between the therapy relationship and
the outcome, independent of the relationship between outcome and specific CBT techniques
(Waddington, 2002; Ilardi and Craighead, 1994; Safran and Segal, 1996).
We do not argue that CBT practitioners neglect the building of strong therapeutic relation-
ships with their patients. Indeed, Beck noted that “slighting the therapeutic relationship” i.e.
minimizing its importance, was a common problem amongst trainee therapists (Beck et al.,
1979, p. 27). On the contrary, a competent CBT practitioner is good at not only applying the
appropriate techniques, but also at building relationships with patients. However, by attributing
all the outcome of CBT to the effect of specific technical aspects of CBT it may be that CBT is
neglecting an important element of its effectiveness. Ironically, many experimental studies in
CBT have implicitly recognized this by randomizing patients to attention controls as placebo
conditions to control for some of these factors. These studies have frequently found that
some patients improve markedly in these groups (e.g. Marks, Lovell, Noshirvani, Livanou and
Self-help 17
Patient
factors
Contextual
factors
Framework
and roles
Therapeutic
meeting(s)
Processes and
outcomes
Processes and
outcomes
Processes and
outcomes
Therapist
factors
Maintaining
relationship
Developing
relationship
Establishing
relationship
Figure 1. Conceptual map of therapist patient interaction (reproduced with permission from Barkham
et al., 2003)
Thrasher, 1998; Elkin, 1994). These “placebo” effects, therefore, may actually be reflecting
the independent agency of common factors.
The above reflections lead to the following question. Is the lesser effectiveness of self-help
a consequence of CBT being implemented without “anaesthesia” or because the independent
therapeutic effect of common factors is being removed from this mode of CBT delivery? It is
logically inconsistent to argue that specific factors are pre-eminent in CBT whilst maintaining
that delivery via therapists is more likely to be effective than self-help. If specific CBT factors
are the main agent of change, their context and delivery mode should be inconsequential.
Therapist-patient interactions and CBT
If one accepts that common factors present in the interaction between patient and therapist
play an important role in the effectiveness of CBT – as they are thought to do in other
psychotherapies – it is necessary to identify these factors and attempt to incorporate them
into self-help, thereby increasing the likelihood that self-help will approximate more to the
effectiveness of traditional CBT. In the same way that the alliance between therapist and
patient is valued by patients as one of their most important mediators of therapeutic effect
(Horvath and Bedi, 2002), there is evidence that common factors are equally important to
patients in guided self-help. For example, in a qualitative study of a guided self-help clinic
(Rogers, Oliver, Bower, Lovell and Richards, 2004) many patients did not use technique-
based attributions of success, even where limited amounts of common factors (in terms of
contact with a self-help facilitator) were available. Instead, many patients used interpersonal
attributional concepts, regarding their improvements as a consequence of “having somebody
to talk to” (p. 44).
A recent review of measures of therapist-patient interactions (TPI) in mental health settings
developed a conceptual map of this subject area (see Figure 1). The authors identified three
developmental processes as necessary for the provision of an effective therapeutic relationship:
“establishing a relationship”, “developing a relationship” and “maintaining a relationship”. The
18 R. Richardson and D. A. Richards
Table 1. Objectives of the three stages in the therapist-patient relationship and the role of common
and CBT specific factors
Objectives Common factors CBT specific factors
Establishing the Positive expectancies; Empathy, warmth and Assessment of patient;
relationship Hope; Patient genuineness; Negotiation Formulation;
engagement of goals; Collaborative Establishing therapist
framework; Guidance competence
Developing the Commitment; Trust in Developing a secure Education; Rationale
relationship therapist; Openness to base; Feedback; giving; Initiating
therapy Responsiveness treatment
Maintaining the Satisfaction; Alliance; Rupture repair; Flexibility Specific treatment
relationship Emotional processing; and responsiveness techniques; Problem
Clinical improvement; solving; Relapse
Preventing drop out prevention
map also detailed key “processes” that therapists use to achieve “objectives” for each phase.
The authors assumed that although therapy progresses through these phases, the therapist
might need to use processes from different phases in a single session, or at times across the
whole course of therapy.
Several of the processes cited, for example “exploration of aspects of the patient-therapist
relationship” are more relevant to other schools of psychotherapy than CBT: a CBT practitioner
would not recognize maintaining a therapeutic relationship as an objective of therapy per
se. With this caveat in mind we have adapted this map to reflect traditional CBT practice
(see Table 1). The relationship phases are retained and mapped against processes and
objectives that are particularly relevant to CBT. We have renamed the processes as “common
factors” to contrast them with specific CBT techniques or factors. We have then matched
these specific factors to the phases of relationship building during which they are mostly
employed.
This revised map highlights the common factors employed during therapist delivered CBT
and the next step is, therefore, to consider how they could be incorporated into self-help
materials. The concept may be counter-intuitive but we aim to demonstrate that this approach
will provide scope for improving the materials currently available. Although the detail is
outside the scope of this paper, there are also lessons that can be learnt from other disciplines.
For example, the design of self-help materials can be seen as similar to designing open learning
materials: both face the challenge of motivating people to continue, to complete homework
assignments, and to fit activities into busy schedules. A brief glance at the open learning
literature reveals an interest in designing materials that can show empathy with students, are
broken into manageable chunks, and allow some flexibility of use (Race, 1993). A recent
paper about preventing dropout from open learning emphasizes the importance of marketing
programmes appropriately to avoid a gap between student expectations and experiences that
can lead to student attrition (Yorke, 2004). Much of this thinking can be seen as the application
of common factors to distance learning educational materials and parallels our own concerns
to incorporate common factors more explicitly into self-help.
We will now consider each of the phases in the provision of an effective therapeutic
relationship in relation to the incorporation of common factors into self-help.
Self-help 19
Establishing the relationship
Perhaps the primary objective in the early stages of building a therapeutic relationship is that
the patient will return for further appointments. Achieving patient engagement is as critical
for the success of self-help materials as it is for traditional therapy. Other objectives include
generating positive expectations of therapy and encouraging the patient to have a sense of
hope about the outcome.
Although empathy, warmth and genuineness are usually considered as skills deployed in
personal relationships, it may be possible for self-help materials to display these characteristics.
Material can appear to have been produced by a concerned individual, who can prove that they
understand the patient’s difficulties by accurately and simply describing what their feelings are
likely to be. The type of language used can convey warmth and caring. The use of accessible
language can signify genuineness of intent, as can a sense of respect for the patient’s suffering.
Indeed, it may be possible for self-help materials to have a “personality”, and this can contribute
to the building of a relationship with the user.
The interactive negotiation of goals may seem to be a process that would be difficult to
replicate in self-help. However, materials can use techniques to enable patients to think about
their aims and write them down, including using examples of the kind of goals that might
and might not be possible. The materials can even provide suggestions for measurement of
progress and dates at which progress could be assessed. The idea of reviewing progress,
and thus encouraging patients to tailor their use of the materials accordingly, leads to the
requirement that materials can be used in a non-linear way. A good analogy is to compare a
self-help manual to the kind of instruction manual that comes with a video or television; the
user only reads the sections that they need (Holdsworth and Paxton, 1999). This requirement
will also be relevant to incorporating other common factors into self-help and will be discussed
in more detail below.
Building a collaborative framework means generating faith in the methods that will be
employed and gaining commitment to working towards the goals that the patient has set. Clear
information about how therapy will work and how the patient will progress is vital to building
this framework. This type of information can also provide guidance to the patient as to how
they might feel at the different stages of therapy. Other important guidance could include tips
on dealing with common stumbling blocks to progress.
Developing the relationship
Once the relationship has been established, the key objective is to ensure that the patient feels
committed to participating in therapy. CBT can be arduous and requires substantial patient
commitment. As noted above, completion of CBT homework by patients has been shown to be
a critical determinant of clinical outcome (e.g. Burns and Nolen-Hoeksema, 1992). Gaining
patient commitment to consistent and regular extra-therapeutic homework activity is crucial
in both therapist mediated and self-help CBT.
Barkham et al. (2003) cite the development of a secure base as one of the processes
important in this phase. They state, “the aim in the therapeutic relationship is to develop a
base from which patients feel secure and able to explore their problems productively” (p. 14).
There are two elements to this secure base: patients need to feel “safe” with their therapist as
well as confident about the treatment techniques that will be used. Generating confidence in
20 R. Richardson and D. A. Richards
treatment techniques involves giving a rationale for the interventions to be used so that the
patient can understand the purpose of various exercises. This type of information giving can be
employed in self-help materials. Other useful techniques might be sections with “frequently
asked questions” that anticipate the kind of questions that are often asked in therapy. The use
of case studies can help patients see what can be achieved, which can also inspire confidence
in CBT techniques.
Generating a sense of safety with the therapist might appear to be more of a challenge
for self-help. However, as we argue above, self-help materials can have a personality and
can appear to be produced by a caring individual who is knowledgeable and experienced.
Descriptions of the support that the materials can offer will also help to generate a sense
of safety. Self-help should also create opportunities for patients to personalize materials (a
concept used in the development of open learning materials), increasing their ability to act as
a secure base.
There is also a challenge in ensuring that self-help materials are appropriately responsive
to patients. Stiles, Honos-Webb and Surko (1998) define responsiveness as “behaviour that
is affected by emerging context” (p. 439). It is clear that self-help materials could never
be acutely responsive on a “moment-to-moment” basis, but they can still be responsive to
emerging context through being used in a non-linear way. Patients need to be able to identify
their own needs and then be able to find the relevant material, linking to the idea of reviewing
progress introduced above.
Giving feedback is important at this stage of the relationship. For example, the use of
simple behavioural activation techniques can provide feedback to reinforce some of the therapy
messages. Some early success will also build confidence in the treatment being proposed.
Maintaining the relationship
Skills crucial to maintaining a successful therapeutic relationship include repairing “ruptures”
in the relationship and being responsive to the changing requirements of the patient. The most
concrete example of a rupture is where a patient drops out of therapy in an unplanned manner. It
should be remembered that retention is a problem for psychological therapies in general, with
reports of between 17 and 40% of patients dropping out from both trials and routine clinical
practice (Churchill et al., 2001; Aubrey, Self and Halstead, 2003). Although it has been noted
that in terms of the broader definition of self-help, “dropping out” is a somewhat counter-
intuitive concept (since “most health care is self-care” (p. S23) (Coulter and Elwyn, 2002),
problems of concordance with specific psychological self-help programmes are significant,
even in the case of computer based self-help programmes that have been explicitly designed
to try and minimize this (Proudfoot et al., 2003, 2004).
This is clearly a very challenging area for the development of self-help materials and it
is likely that many patients will require one-to-one support as they progress. At this stage it
becomes increasingly difficult to see how self-help materials alone could adequately respond
to these challenges. Some form of interpersonal guidance sitting alongside self-help materials
might be needed to encourage patients to continue and deal with any problems.
However, there are potential ways in which materials can anticipate difficulties and attempt to
provide strategies against possible ruptures in the relationship. As discussed above, materials
can be designed in a non-linear fashion so that patients have places to turn to if they are
experiencing difficulties. The use of “appointments” within self-help materials could be
Self-help 21
considered as a way to generate commitment and sections might be included on how to
recommence therapy if a rupture has occurred. Honesty about possible setbacks (and how
these can be overcome) may help to counter some difficulties.
Conversely, one might also argue that self-help has distinct advantages over traditional
therapy in preventing ruptures in terms of accessibility. If materials are structured in a flexible
way, they can answer the questions and fears that arise in the middle of the night, as well as
during office hours. Patients can also undertake therapy at times convenient to them, without
having to worry about, for example, taking time off work. They are also easier to pick up again
after a rupture, whereas rearranging therapy might be more difficult.
Conclusions
The challenge of meeting the need for treatment of depression and anxiety is well recognized.
Self-help materials have the potential to contribute to meeting this need. However, recent
research has cast doubt on the effectiveness of the current generation of these materials.
One potential reason for this might be the lack of explicit attention paid to reproducing the
“common factors” present in CBT therapy within self-help materials. The development of
the next generation of self-help materials, therefore, may benefit from the testing of materials
that combine common and specific factors, including specific measurement of the strength
of common factors and their relationship to clinical outcomes. Given that self-help is a
core component of the NICE Guidelines for anxiety and depression (National Institute for
Clinical Excellence, 2004a, 2004b), such research and development is urgently required to
meet the aspirations and the assertions of both these guidelines and the NSF for mental health
(Department of Health, 1999), aimed as they are at improving the desperately poor availability
of psychological therapies in the UK at the current time.
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