Cognitive Behaviour Therapy for Depression and Anxiety

Introduction to Blues Begone research

For those of you looking into cognitive behaviour therapy for depression or anxiety I wanted to provide as much information as possible about the user experience of Blues Begone.

Research
So, this is part two of the Blues Begone User Experience looking at research into self-help programmes.

Within the field of mental health, the potential therapeutic benefits of self-help programmes are currently the focus of increased attention from the research community.  A review of the literature suggests that such interest is being driven by some very practical concerns.

Whilst the National Health Service seeks to provide a range of psychotherapies to address psychological problems, access to services is often restricted owing to a high level of demand and a limited availability of appropriately trained therapists (National Institute of Clinical Excellence, 2006).

This is particularly true of services offering Cognitive-Behavioural Therapy (CBT).

CBT therapy has been shown to have the greatest evidence base for effectively treating depression, panic and generalised anxiety disorders and as such is recommended as the treatment of choice for these conditions (NICE Guidelines, 2004a, 2004b).

Understandably, demand for CBT is high, yet there are large disparities in the availability of CBT therapists across the United Kingdom and consequent restrictions in the choice of treatment available (The Centre for Economic Performance’s Mental Health Group, 2006).

Cognitive Behaviour Therapy for Depression and Anxiety: Availability of treatment

By developing self-help programmes within a CBT framework, it is hoped that access to effective psychological support will be improved.  Indeed, “the possibility of making available beneficial treatments for those who might otherwise go unserved is one of the great potentialities of self-administered therapy” (Scogin, 2003).

But to what extent are self-help treatments useful and acceptable for those seeking psychological help?  A broad review of the research literature past and present reveals some promising findings.

 Cognitive Behaviour Therapy for Depression and Anxiety: Existing research

As early as 1993, Gould and Clum analysed the findings of forty self-help studies where participants had used media-based treatments (book, manual, audiotape or videotape, or some combination) to address their problems largely independently of a helping professional.

Studies
Results of this analysis indicated that the self-help approaches investigated were effective in addressing the kinds of problem that they targeted, with treatments for anxiety and depression being found to be more effective than those for habit behaviours such as smoking and drinking.  No significant differences were found between end-of-treatment and follow-up data, suggesting that participants using self-help interventions generally maintained their treatment gains; and interestingly, an examination of twelve studies that compared self-help and therapist conditions revealed there to be no statistical difference in outcome between the two.

Cognitive Behaviour Therapy for Depression and Anxiety: Recent Reviews

In a more recent review of self-help therapies, Mains and Scogin (2003) described similar outcomes, reporting a decade later that self-help treatments have been shown to be effective in alleviating depression, anxiety disorders and mild alcohol abuse; but less successful for smoking cessation and moderate to severe alcohol abuse.

With specific reference to computerised self-help treatments, Christensen and Jacobson (1994) cited a number of studies where computer-administered therapy was shown to achieve results comparable to traditional “face to face” therapy in the treatment of depression and anxiety; and in a more recent review of self-administered treatments for depression, McKendree-Smith, Floyd and Scogin (2003) reported similar findings, though went on to highlight that evidence from inpatient studies indicated that this mode of therapy may not be suited to the more severely depressed.

Cognitive Behaviour Therapy for Depression and Anxiety: Computerised self-help programmes

As highlighted previously, research into the application of computerised self-help programmes has gained particular prominence within the National Health Service, where the results of fourteen studies involving the use of five computer-assisted self-help packages have recently been evaluated.

Young woman working with computer
After taking into account both the clinical and cost effectiveness, and patient acceptability of the different programmes, the National Institute for Clinical Excellence has now recommended that the computerised CBT package, “Beating the Blues” should be offered as an option for delivering CBT in the management of mild and moderate depression, and the computerised CBT package “Fearfighter” be offered as an option in the management of panic and phobia (NICE, 2006).

Cognitive Behaviour Therapy for Depression and Anxiety: Other Recommendations

At this stage, the committee did not recommend the use of computerised CBT in the treatment of Obsessive Compulsive Disorder, acknowledging amongst other factors patient preference for therapist administered treatment in this particular instance (NICE, 2006).  Notwithstanding this particular concern, the recommendations from the National Institute for Clinical Excellence are significant and would appear to add weight to previous research evidence supporting the use of self-help activity to address mild to moderate depression and anxiety disorders.

Cognitive Behaviour Therapy for Depression and Anxiety: Rigour of the Studies

However, it should be noted that some authors have questioned the level of scientific rigour with which previous studies of self-help have been conducted, thus casting some doubt on the reliability of results (see Kaltenthaler, Parry and Beverley, 2004).  Whilst there is a body of research indicating that self-help interventions can be effective in alleviating psychological distress, this is not always the case, and the potential factors that influence positive or negative outcome remain unclear.

Cognitive Behaviour Therapy for Depression and Anxiety: Client/ Therapist Relationship

In seeking to develop our understanding of the factors that may influence a positive outcome in self-help treatments, Richardson and Richards (2006) acknowledge the widely held view that the relationship between the therapist and client is an important factor in determining a successful therapeutic outcome (see Hovarth & Bedi, 2002).

cognitive-behaviour-therapy-for-depression-and-anxiety-client-therapist-relationship
Thus they argue that the ability of self-help materials to “recreate” the positive aspects of the patient’s relationship with a therapist could be a factor in influencing the effectiveness of self-help programmes.

They contend that positive characteristics associated with the therapist such as warmth and credibility can and should be adapted to the self-help media through a considered use of wording, user friendly presentational techniques etc.   Indeed it is proposed that the more explicitly such factors are incorporated into self-help materials, the more likely it is that clients will become engaged in the self-help process, thereby increasing the likelihood of a positive outcome.

 Cognitive Behaviour Therapy for Depression and Anxiety: Patient Expectation

Other authors have suggested that patient expectation of self-help treatment may be significant in determining its effectiveness.  In a rare exploration of the individual’s experience of self-help activity, Rogers, Oliver, Bower, Lovell and Richards (2004) noted that some patients attending a Primary Care self-help clinic, experienced “a sense of dissonance” between prior expectations and their actual use of the self-help clinic, and were unprepared for the degree to which they were required to be a change agent within the self-help process.

This mismatch between expectation and reality had a negative effect on patient engagement in self-help activity and the consequent therapeutic outcome.

Cognitive Behaviour Therapy for Depression and Anxiety: Outcome Focused Research

Despite the work of Rogers et al., the majority of research in the field of self-help is still heavily outcome focusedwith investigators asking to what degree are self-help programmes effective in treating specific conditions or comparable in outcome to more traditional forms of therapy.  The process of self-help has received less attention from researchers and the issue of how clients are able to make use of self-help treatments to alleviate distress appears to be less clearly understood.   Authors within the wider field of psychotherapy have offered some perspectives on the concept of self-help that may inform our understanding of the client’s process in self-help activity.

Cognitive Behaviour Therapy for Depression and Anxiety: Symbolisation

In their comparative study of psychotherapy, Frank and Frank (1991) highlight human powers of symbolisation, and argue that in the case of self-help treatments, the process of change is still supported by a therapeutic relationship but one that functions in symbolic form, the patient engaging in a “relationship” with a self-help material that carries the therapist’s authority.

They also suggest that in the absence of a “live” therapist, the novelty of the self-help media might stimulate new hope in people for whom previous types of help might have failed, hope being an important factor in therapeutic outcome (Ilardi & Craighead, 1994).

Cognitive Behaviour Therapy for Depression and Anxiety: Self-Help

Bohart and Tallman (1999) offer a humanistic perspective on the process of self-help, suggesting that ultimately it is the client rather than the therapist who is the primary agent of change; thus all therapeutic endeavours can be interpreted as examples of “self-help”.  When an individual’s own abilities to deal with problems are insufficient or overwhelmed, the therapist is but one possible resource facilitating change within the client; self-help activity is another.

Cognitive Behaviour Therapy for Depression and Anxiety: The present study

The potential benefits of individuals being able to “help themselves” to address mental health problems are far-reaching.

cognitive-behaviour-therapy-for-depression-and-anxiety-helping-yourself
 

Whilst computerised CBT programmes can be used to support the overburdened NHS, they also offer increased choice for those who are seeking help but do not wish to interact with a therapist or the mental health services; they provide opportunity for those who because of geographical distance or physical disability may not be able to engage with traditional services; and offer 24-hour availability for the individual to access support at his or her convenience, in the privacy of his or her own home or other location of their choice.

Within the field of mental health, self-help has been researched and written about from different practical, theoretical and philosophical positions.

Yet despite increased interest in self-help activity, there is a paucity of research exploring the experience of individuals as they engage in the self-help process. Thus the study that follows seeks to explore this experience, hoping to further our understanding of the ways in which individuals find self-help therapy useful in alleviating psychological distress.

http://www.bluesbegone.co.uk/

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