Evidence-Based Adjunctive Treatments

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EVIDENCE-BASED ADJUNCTIVE THERAPY

INTRODUCTION

WILLIAM T. O’DONOHUE* and NICHOLAS A. CUMMINGS†,     *University of Nevada, Reno; †The Cummings Foundation for Behavioral Health

Publisher Summary

This chapter addresses the importance of both adjunctive therapies and stepped care. Evidence-based adjunctive therapies should be considered in this strategic vision as they can be helpful, client preferred, less expensive, less intrusive, offsetting of the therapist’s weaknesses, and more comprehensive. However, there may be times when what is considered here as an adjunctive therapy may serve as the main intervention. There has to be a strategic vision for the therapist to address the situation of a patient. One of the implications of this model is that most of the benefit that the patient will receive from this interaction would directly flow from what the therapist can provide. If the therapist’s skills in the room are good, the hope is that the client will make progress on his or her problems. Thus, any limitations in this skill set will limit the benefit the client can receive from therapy. Additionally, the one-on-one format is labor-intensive and thus expensive to the patient. Adjunctive is defined by Webster’s dictionary as something attached to another in a dependent or subordinate position. Thus, we are not thinking of adjunctive interventions as replacing needed face-to-face therapy but something most often in addition to usual therapy.

Psychotherapy is often thought of as solely a dyadic phenomenon. To be sure, there are group psychotherapy models and family systems models that involve additional people, but the prototypical depiction of psychotherapy is that it almost exclusively involves just two individuals: the patient and the therapist. One of the implications of this model is that most of the benefit that the patient will receive from this interaction would directly flow from what the therapist can provide. The therapist’s skills in the room are essentially the best and only hope the client has to make progress on their problems. Thus, any limitations in this skill set will limit the benefit the client can receive from therapy. Additionally, the one-on-one format is labor-intensive and thus expensive to the patient.

One obvious critique of this approach is that it is risking too much on the particular therapist, as we know that therapists vary considerably. These variations include such dimensions as

(1) professional degree (psychiatrist, doctoral psychologist, masters level psychologist, social worker, counselor, marriage/family therapist);

(2) general level of experience (intern, newly licensed, mid or advanced career);

(3) level of experience with the particular presenting problem;

(4) theoretical orientation or school of psychotherapy;

(5) general competence at the proper diagnosis and treatment for the client’s particular array of problems;

(6) skills at the nonspecifics;

(7) gender, race, and other cultural variables;

(8) expense (fee charged) and availability on patient’s insurance panel;

(9) personal qualities such as intelligence, general problem-solving ability, life experience, sensitivity, relatedness, charisma.

We have named just a few relevant variables. One can imagine particular combinations of these (and other variables) having a felicitous influence on a particular client’s prospects for change. On the other hand, one can also imagine arrays of these variables which would not be the cause for optimism, and may even have a negative effect.

In an attempt to compensate for this, variation has been the movement toward treatment by teams of professionals. These teams often comprise individuals from diverse professional backgrounds (e.g., physicians, substance abuse specialists, behavioral medicine specialists) and, indirectly, will often be diverse on one or the other helper dimensions listed above. A basic premise of this approach is that a client may need not just the expertise of a single discipline but the nature of the client’s problem is best suited for a multidisciplinary approach. For example, an individual who is depressed, has gained weight and has been drinking too much may need a team consisting of a primary care physician (to monitor general health issues), a psychiatrist (to prescribe antidepressants), a substance abuse specialist (to address the problematic drinking), a nutritionist (to address obesity), and a psychologist (to provide psychotherapy for the depression and to help with a self-control obesity program). A key to such teams is that the treatment is in fact coordinated as opposed to each independently working with little or no knowledge of the others. An advantage of this model is that there can be many eyes on the case; so if some professional is dropping the ball, others can notice. Such coordination does not come automatically or even easily but must be planfully structured. These teams again may be more or less successful due to other classes of variables (e.g., cohesiveness of the team, experience in working together, and actual competence of individual members).

There are two serious problems with the team approach: (i) It can be very labor-intensive and thus prohibitively expensive. Third-party payers are unlikely to approve the expenditure unless highly justified, forcing the patient to pay out of pocket. Few patients are in a position to assume such expense, especially if there are cheaper alternatives, (ii) It can be unavailable. There are many rural and frontier areas or other areas underserved by healthcare professionals, making such teams simply not available.

THE ADJUNCTIVE MODEL: THERAPIST AS STRATEGIST

This volume is predicated on the view that the therapist needs to develop a case formulation, address these issues, and respond to questions such as the following:

(1) What constitutes a comprehensive assessment plan, case formulation, and treatment design for this client?

(2) What does the client (and others legitimately affected) prefer with respect to the above?

(3) What comprises a good financial value for the client and other payers?

(4) What is the minimally intrusive intervention for this client?

(5) As a therapist, what are my strengths and limitations with respect to the above and how can the latter be offset by other resources?

We believe these questions will provide a strategic vision for the therapist regarding each case. The second premise of this book is that evidence-based adjunctive therapies should be considered in this strategic vision as they can be (1) helpful, (2) client preferred, (3) less expensive, (4) less intrusive, (5) offsetting of the therapist’s weaknesses, and (6) more comprehensive.

Adjunctive is defined by the Webster’s dictionary as something attached to another in a dependent or subordinate position. Thus, we are not thinking of adjunctive interventions as replacing needed face-to-face therapy, but something most often in addition to usual therapy.

A CASE ILLUSTRATION

Steve is a 42-year-old recently divorced father of two boys aged 6 and 9 years. He has graduated from college and runs a small computer repair business. He presents with complaints of crying, fatigue, and anger. He was divorced about 6 months ago after discovering that his wife was having a longstanding affair with her boss for 15 years. He has gained about 25 lbs in the last 9 months. His Beck Depression Inventory (BDI) is 16 with no indications of suicide ideation and a history of suicidal behavior. He reports that his depression is a reaction to his divorce, and he states he has no history of depression. His primary care physician recently diagnosed him with type 2 diabetes and reports that he is having trouble being treatment compliant. He lives in a small rural community about 1 hour’s drive from the therapist’s office, and there are no other mental health professionals practicing closer to his home. He was previously on his wife’s insurance plan, and since the divorce he has no health insurance coverage.

One option would be for the therapist to attempt to treat all of Steve’s problems. He could come in for evidence-based cognitive behavior therapy (CBT) for his mild depression and the therapist could also treat his diabetes noncompliance, his obesity, and his anger. In addition, he could help him cope with his divorce and his feelings of loss. Some of these targets, of course, may dissolve with success at initial treatment targets. However, this therapy could be rather long term and expensive in both time and money.

An option to be considered by the therapist in this case would be to assess what is the best use of my professional expensive time in this case and what adjunctive resources can be used to leverage the client’s money, time, and commitment? This option might result in the therapist recommending the client to read David Burn’s Feeling Good (an evidence-based bibliotherapy book) for his mild depression, recommending involvement in a diabetes disease management group at the local hospital based on the work of Dr Kate Lorig at Stanford, and seeing the client for six individual therapy sessions to treat his anger and difficulty in coping with the divorce. The client was presented with both options and he chose the second. However, he was told the diabetes self-management group is full and instead was recommended that he participate in the Internet version: Self-Management @ Stanford: Healthier Living With Diabetes (Internet) http://patienteducation.stanford.edu/internet/diabetesol.html

It is this kind of strategic vision we would like this book to help encourage in therapists. The therapist discerns the options and gives the client a choice. In so doing, the therapist is responding to the person’s financial and time constraints and offers adjuncts that are sensitive to these. However, all the while the therapist is insisting that the treatment options be evidence-based (Fisher & O’Donohue, 2006).

We believe this treatment can be

(1) helpful (the evidence would suggest improvement in the all the treatment targets);

(2) client preferred (the client appreciated the wide scope of different expertise as well as the convenience and much lower costs of some of the methods of service delivery);

(3) less expensive (the book Feeling Good was less than $10 and the Internet group was less than $300);

(4) less intrusive. Both the book and the Internet therapy allowed less intrusion into his busy schedule, with less stigma and more privacy.

(5) Offsetting of the therapist’s weaknesses. The therapist was not trained in diabetes disease management and thus was grateful that this client’s need could be handled through other expertise.

(6) More comprehensive. The client’s depression, diabetes management, and coping problem with the divorce were handled by the therapist. These three treatment targets were thought to be sufficient initially, as the therapist did not want the client overwhelmed. If the depression could be reduced, the client’s health problems (and obesity) would improve along with his adjustment to the divorce be improved. With these changes it was likely that the client would no longer need therapy, as his life would be much more satisfactory to him.

ADJUNCTIVE THERAPY IN A STEPPED CARE MODEL

However, there may be times when what is considered here as an adjunctive therapy may serve as the main intervention. For example, if someone presents with concerns about a very low level depression, a stepped care model could involve something like

(1) watchful waiting;

(2) self-monitoring;

(3) bibliotherapy;

(4) Internet therapy (such as Seligman’s AuthenticHappiness.com);

(5) prescription of exercise;

(6) support group;

(7) psychotherapy group;

(8) individual psychotherapy;

(9) medication;

(10) inpatient treatment.

As one goes up these steps, intrusiveness, cost, and in general treatment intensity increase. The following chapters will describe these in more detail and provide the evidence base. Stepped care is partly based on the following notions:

(1) Many of the problems we as mental health professionals deal with have very large incidence rates (e.g., depression, anxiety, obesity, oppositional defiant disorder) and thus would overwhelm the mental health system if all who suffered from these would present for tertiary care. Thus, public health approaches that are scalable to large numbers are needed. It is not an overall good strategy to perpetuate the present system based on the expectation that most individuals suffering from a problem simply will not present for treatment.

(2) Triage to the appropriate step may be necessary. However, in many cases it is permissible to fail up, i.e., what appears to be a reasonable step for a particular individual (say bibliotherapy) is initiated, and if this fails, a higher step is then attempted (e.g., Internet therapy).

(3) Client preferences can also play a role in what step is tried. In stepped care, clients are given a lot of options. There is not a one size fits all mentality that is too common in our profession—the one size being one-to-one therapy for most mental health professionals or medications for medical professionals.

(4) Stepped care is a more affordable way to treat populations of individual suffering with many problems.

It is also possible that a client is from the start given a lower step therapy that we here consider adjunctive. This would normally be the case for clients whose problems are less intense, who may prefer these modalities, who cannot access higher level steps (geographical or financial reasons), or who may not want the stigma of psychotherapy (e.g., military personnel). This is common in many aspects of healthcare. Consider, for example, how often a urologist, after thoroughly examining an octogenarian male with a benignly enlarged prostate gland, recommends watchful waiting instead of a prostectomy. The same urologist might recommend watchful waiting in a very elderly man who already has early prostate cancer inasmuch as the cancer is so slow-growing that it will outlive the life span of the patient. The surgeon may further ascertain that allowing the slow-growing prostate cancer has a better prognosis than subjecting a man of very advanced age to the side effects of major surgery. Such determinations are common throughout medicine and surgery, but are uncommon in mental healthcare. This book addresses the importance of both adjunctive therapies and stepped care.

THE ORGANIZATION OF THIS BOOK

The book is broadly organized into two sections. The first gives a general overview of the major adjunctive modalities, whereas the second concentrates on a systematic description of their role in the treatment of a number of special populations.

The authors were asked to write their chapters in the following format:

(1) Basic description of the intervention with some examples.

(2) Outcome data:

(a) Cost-efficiency;

(b) Demonstrated range of applicability;

(3) The key process variables.

(4) The role in comprehensive treatment planning or stepped care and the coordination issues.

(5) The research agenda.

(6) The dissemination agenda.

REFERENCES

Fisher, J. E., O’Donohue, T. Practitionar’s Guide to Evidence-Based Psychotheraphy. New York: Spaiwuer, 2006; .

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BIBLIOTHERAPY AS AN ADJUNCTIVE TREATMENT

READ ALL ABOUT IT

NEGAR NICOLE JACOBS* and ELIZABETH MOSCO†,     *Department of Psychiatry and Behavioral Sciences, University of Nevada School of Medicine, Reno, NV; †Veteran’s Administration Sierra Nevada Health Care System, Reno, NV

Publisher Summary

This chapter defines bibliotherapy as psychotherapeutic programs presented in a written self-help format as opposed to fictional stories or religious texts. It outlines the research literature regarding the clinical effectiveness and cost-effectiveness of bibliotherapy for a wide variety of problems. It discusses the literature on process variables leading to therapeutic change in patients utilizing bibliotherapy. It addresses the role of bibliotherapy within the context of a stepped care and integrated care environment. It proposes adjunctive treatment as a research and dissemination agenda for the use of bibliotherapy. There are many obvious advantages to bibliotherapy over traditional psychotherapy such as the ability to self-pace, allowing individuals who are unable to receive mental health services due to geographical or transportational barriers receive treatment and providing cost-effectiveness for those who cannot afford psychotherapy or pharmacotherapy, privacy that can lessen stigmatization or labeling, and coping skills for life after treatment has ended. Despite these benefits, there are still many unknowns in the area of bibliotherapy such as for whom it is effective, for which psychological problems it is effective, what degree of adjunctive professional or nonprofessional help is needed, and what role bibliotherapy can play in integrated health care systems.

There are many obvious advantages to bibliotherapy over traditional psychotherapy such as the ability to self pace, allowing individuals who are unable to receive mental health services due to geographical or transportational barriers receive treatment, cost-effectiveness for those who cannot afford psychotherapy or pharmacotherapy, providing individuals with privacy that can lessen stigmatization or labeling, and providing individuals with coping skills available after treatment has ended (Scogin et al., 2003). Despite these benefits, there are still many unknowns in the area of bibliotherapy such as for whom it is effective, for which psychological problems it is effective, what degree of adjunctive professional or nonprofessional help is needed, and what role can bibliotherapy play in integrated health care systems. We are defining bibliotherapy in this chapter as psychotherapeutic programs presented in a written self-help format as opposed to fictional stories or religious texts.

This chapter is intended to address these issues: First, the research literature regarding the clinical effectiveness and cost-effectiveness of bibliotherapy for a wide variety of problems will be outlined. Second, the literature on process variables leading to therapeutic change in patients utilizing bibliotherapy will be discussed. Third, the role of bibliotherapy within the context of a stepped care and integrated care environment will be addressed. Finally, research and dissemination agendas for the use of bibliotherapy as an adjunctive treatment will be proposed.

OUTCOME DATA

COST-EFFICIENCY

The economic impact of mental health problems nationwide is staggering. The financial burden exceeds $148 billion annually [National Institute of Mental Health (NIMH), 2000]. The costs associated with depression alone have increased from $44 billion in 1990 (Greenberg et al., 1993) to $83 billion in 2000 (Greenberg et al., 2003). Depression and anxiety disorders are associated with an increased use of general medical services, which in turn results in decreased resources for other patients, as well as increased costs to the patient, other taxpayers, and the insured public (Chiles et al., 1999). The intricate nature of integrated healthcare makes it difficult, if not impossible, to accurately predict the cost-effectiveness of a psychological intervention for the provider or the patient. Factors such as costs of implementing the intervention (salaries of providers, written or video materials, medication costs including testing for efficacy and safety, etc.), costs of subsequent medical utilization, and costs to the patient such as lost wages and productivity at work all must be considered when determining the cost-effectiveness of a psychological intervention (Gabbard et al., 1997).

Besides the obvious cost decrease when reading a $10 book as opposed to 12 sessions of psychotherapy with a psychologist billing at $150 per session, bibliotherapy may have more subtle financial benefits for patients and health care systems. One must remember that it is not only the monetary cost of therapy (e.g., $90/h) but also the transportation, child care, and opportunity costs that must be included in the comparison. As many as 25% of primary care outpatient visits can be accounted for by psychological factors that cause physiological disturbance with no permanent organ damage (migraines, functional bowel disease, types of chronic pain), and this rate rises to 50% if this is broadened to include conditions where actual physiological changes occur (hypertension, asthma, chronic skin disorders; Paulter, 1991). Researchers have found that brief psychotherapy can reduce patient stress levels, related physical symptoms, and overall medical costs (Cummings, 1993).

Jones (2002) evaluated the role of bibliotherapy in reducing health anxiety, which can lead to panic attacks, inability to cope, or depression. Health anxiety arises from the misinterpretation of bodily symptoms, leading patients to seek assurance from medical professionals and draining medical resources (Barsky et al., 1991). Smit et al. (2006) found that adding minimal contact bibliotherapy to the usual care of patients seen in primary care with subthreshold depression resulted in improved outcomes and generated lower costs over a 1-year period. The intervention resulted in a 30% decreased risk of developing a full-blown depressive disorder among participants.

In an interesting study of a manual-based behavioral therapy for obesity, different levels of therapist contact had minimal impact on the overall effectiveness of the treatment (Pezzot-Pearce et al., 1982). Obesity can lead to numerous costly physiological and psychological complications including hypertension, diabetes, cancer, osteoarthritis, stroke, sleep apnea, depression, and eating disorders, among many more. Researchers found that a 15-minute investment of therapist time during treatment resulted in a maintained 11-pound loss 6 months later. A 60-minute investment resulted in no additional loss, and a 300-minute investment resulted in 1 additional lost pound. The authors note that the findings should make all therapists involved in obesity treatment seriously question not only the program effectiveness but perhaps more important, program efficiency as well (p. 449). This study is a clear example of additional intervention not necessarily resulting in better outcomes. Fifteen minutes of a therapist’s time versus 300 minutes of a therapist’s time would have huge cost implications for the patient and the health care system resources. Clearly, bibliotherapy can play a significant role in reducing costs in integrated health care systems.

DEMONSTRATED RANGE OF APPLICABILITY

Treatment outcome studies involving bibliotherapy have proliferated over the past couple of decades. These studies encompass a wide range of psychological disorders and severities, as well as different levels of therapist assistance. The following is a representative review of the current research utilizing bibliotherapy with some of the most prevalent mental health problems.

Mood Disorders

Depression

Depression is now the leading cause of disability in the United States (NIMH, 2000). The World Health Organization (WHO) expects depression to be the most serious medical disease by the year 2020 (Murray & Lopez, 1997). Given these sobering statistics, it is no surprise that researchers have been evaluating treatments for depression, including bibliotherapy, for decades. Several meta-analyses of bibliotherapy for depression have also been conducted in order to examine the numerous research findings, with mostly promising results. Scogin et al. (2005) meta-analyzed four cognitive bibliotherapy treatment studies for geriatric depression (Floyd et al., 2004; Landreville & Bissonnette, 1997; Scogin et al., 1987, 1989). Each of the studies utilized David Bums’ Feeling Good (1980), and typically involved reading and written exercises to be completed away from a clinic at the participant’s own pace over a 4-week period. Researcher or therapist contact consisted of weekly telephone checkups of less than 5 minutes. All these studies led to significant improvement in depressive symptoms among participants.

Cuijpers (1997) also found in a meta-analysis of six studies addressing bibliotherapy for depression that overall bibliotherapy was as effective as individual or group therapy. McKendree-Smith et al. (2003) also reviewed several bibliotherapy studies for depression and concluded that those who have been used in clinical trials have effect sizes that are equivalent to the average effect sizes in traditional psychotherapy studies. In yet another meta-analysis, Gregory et al. (2004) evaluated 29 cognitive bibliotherapy studies for depression. Bibliotherapy was found to be effective in improving depressive symptomatology in adolescent, adult, and older adult age groups. With the adolescent depression rate rising, as well as suicide and suicide attempts among adolescents (National Center for Health Statistics, 1992), finding means to provide treatments such as bibliotherapy to possibly reluctant teens is crucial. Ackerson et al. (1998) found a 4-week bibliotherapy with weekly telephone calls to be beneficial for adolescents experiencing mild and moderate depressive symptomatology.

Initial improvements gained from bibliotherapy for depression also appear to hold up at follow-up assessments. Floyd et al. (2006) conducted a 2-year follow-up of a study examining bibliotherapy versus individual psychotherapy with depressed older adults (Floyd et al., 2004). Although the individuals who participated in bibliotherapy had more recurrences of depression during the 2-year period, overall treatment gains on depression scale scores were maintained with no significant differences between treatment groups. Jamison and Scogin (1995) also found that bibliotherapy resulted in statistically and clinically significant improvement initially, and treatment gains were maintained at a 3-year follow-up (Smith et al., 1997). This research is encouraging to support bibliotherapy as a treatment for depression.

Although the research is promising, it is also important to be critical of the conclusions drawn from bibliotherapy research. For example, Anderson et al. (2005) evaluated 11 randomized control trials of bibliotherapy for depression. The authors found some evidence supporting the use of bibliotherapy; however, the studies they used in their analyses had relatively small sample sizes and were overall of a poor quality (p. 390). The authors also caution about the generalizability of bibliotherapy research to the primary care setting, where many, if not the majority of patients, are seeking and receiving treatment for depression as well as a myriad of other mental health problems (Cummings, 2003).

Anxiety Disorders

Estimates by the US Department of Health and Human Services (2006) indicate that approximately 44 million adults in the United States currently meet criteria for an anxiety disorder. DuPont et al. (1996) reported that anxiety disorders are the most costly mental illness ($46.4 billion), accounting for 31.5% of total expenditures for mental illness. As in the case of depression, these data have led to numerous evaluations of bibliotherapy for anxiety in an effort to meet the mental health demand. Several of these studies have utilized brief, non-psychotherapeutic contact, which proved to have a positive effect on treatment outcomes. Reeves and Stace (2005) examined the use of an assisted self-help treatment package for mild to moderate stress/anxiety with an adult population referred by their general practitioner. Assisted bibliotherapy consisted of 8 weeks of intervention, during which time participants read a cognitive-behavioral bibliotherapy package and engaged in 7 weekly 20-minute one-to-one coaching sessions. There was significant improvement at posttreatment and at a 3-month follow-up. The researchers also found that 75% of participants found the bibliotherapy materials very helpful, lending to bibliotherapy’s face validity for potential consumers. Bowman et al. (1997) evaluated self-examination therapy (SET) in a bibliotherapeutic format over 4 weeks with therapist contact only to answer questions about carrying out the written material with no therapy provided. SET participants had a significant reduction in anxiety symptoms versus a delayed treatment condition, and these gains were maintained at a 3-month follow-up. The use of bibliotherapy in the treatment of anxiety disorders appears to be valuable, at least in some cases.

Febbraro (2005) investigated the effectiveness of bibliotherapy and minimal contact interventions in the treatment of panic attacks. Minimal contact in this study consisted of phone calls lasting no more than 15 minutes at weeks 2, 4, 6, and 8 of the 8-week intervention period. Results indicated that individuals receiving bibliotherapy and bibliotherapy with phone contact exhibited significant reductions on panic cognitions and fear of having a panic attack at posttreatment as well as clinically significant improvement on most dependent measures as compared with that in phone contact alone. Individuals in the bibliotherapy with phone contact condition demonstrated reduced panic symptoms and avoidance posttreatment. However, a significantly higher proportion of participants in the bibliotherapy with phone contact condition were more panic free than participants in the bibliotherapy-alone condition at posttreatment.

Sharp et al. (2000) investigated different levels of therapist contact using a cognitive-behavioral therapy (CBT) manual for panic disorder and agoraphobia in primary care over 12 weeks. A total of 104 patients were assigned to either standard therapist contact (eight 45-minute sessions), minimum contact (six 30-minute sessions), or bibliotherapy alone. Results indicated that bibliotherapy alone showed the weakest overall treatment response. Although this group showed significant improvements in global symptom severity and disruption in social life, there were no significant improvements in disruption of work and home life. The minimum contact group showed significant improvement on all measures, albeit modest. The standard contact group demonstrated the most significant and comprehensive treatment response, with a huge improvement in global symptom severity. This research emphasizes the use of bibliotherapy as an adjunct to, as opposed to stand alone, treatment in some cases.

Wright et al. (2000) investigated a bibliotherapy approach to relapse prevention in panic attacks. The study involved three phases: Phase 1 examined the effectiveness of assessment and feedback; Phase 2 examined the effectiveness of bibliotherapy and monitoring; and Phase 3 involved incorporating a self-help relapse prevention program for individuals completing the first two phases of the study with phone contact. The results of Phase 3 indicated that ongoing minimal phone contact with participants may be necessary for bibliotherapy-based interventions to be effective for individuals with panic problems.

In some cases, bibliotherapy has not proven to be as effective as standard psychological treatments but is significantly more effective than no treatment. Rapee et al. (2006) compared standard group therapy, waitlist, or a bibliotherapy version of treatments for childhood anxiety. Bibliotherapy was found to be beneficial to children compared with the waitlist group, but standard group treatment was found more effective in reducing anxiety. Nonetheless, relative to the waitlist condition, bibliotherapy with no therapist contact still resulted in approximately 15% more children being free of an anxiety disorder diagnosis after 12 and 24 weeks. Thus, bibliotherapy may be an effective option when traditional treatment is not immediately accessible, such as when clients are on a waitlist.

Hirai and Clum (2006) found in a meta-analytic study of self-help approaches for anxiety problems that self-help interventions were helpful and produced slightly less effect sizes than therapist-directed interventions. This study also found that dropout rates were comparable in both groups and were not related to diagnostic criterion. This implies that individuals with more severe anxiety problems can view self-help interventions as a viable treatment option as well as those with less severe symptoms. Den Boer et al. (2004) also conducted a meta-analysis of self-help treatments for mood disorders. Their analysis also showed a robust effect for bibliotherapy as a treatment for anxiety and depression, which might be chronic and recurrent.

In a review of bibliotherapy studies of anxiety disorders, Newman et al. (2003) found that bibliotherapy was the most effective for specific phobias. Pure self-help for panic disorder was not significantly different from a self-monitoring or waitlist condition, and self-help for obsessive-compulsive disorder (OCD) led to minimal change. However, when minimal therapist contact (check-ins, teaching to use self-help, rationale) was included, self-help was found to be more effective than waitlist for OCD and generalized anxiety disorder (GAD). This type of self-help also showed improvement in mixed anxiety disorder samples. The authors concluded that participants were most likely to respond to minimal contact self-help if they were motivated, their symptoms were not extremely severe, they were not too disabled from their symptoms, they were younger, had no personality disorders, and had not had recurrent bouts of anxiety. Treatment studies of bibliotherapy in the treatment of anxiety disorders has yielded encouraging results.

Alcohol Abuse

Between the years of 2001 and 2002, 9.7 million adult Americans met the DSM-IV criteria for alcohol abuse and 7.9 million Americans for alcohol dependence (Grant et al., 2004). Alcohol problems are notoriously difficult to treat, which has led researchers to focus on brief interventions that can be widely disseminated to prevent severe and difficult-to-treat cases of alcohol problems (Bien et al. 1993).

Apodaca & Miller (2003) conducted a meta-analysis of the effectiveness of bibliotherapy for alcohol problems using 22 research studies. They defined bibliotherapy as any written format of therapeutic intervention with a maximum of one session with a therapist, physician, or other health case worker. A relatively large effect size of 80 was found for bibliotherapeutic interventions. With the populations studied in bibliotherapy research, average effect size does not seem to increase significantly by adding more therapist intervention to bibliotherapy. Studies with longer follow-up periods (up to 8 years) have consistently shown little reversal in any of the initial reductions in drinking. Maintenance gains in one study were better for bibliotherapy over extensive outpatient treatment (Miller et al., 1980). These astonishing results led Miller to conclude: There appears to be a segment of North American and European populations with heavy drinking and alcohol-related problems who will access self-help materials if readily available, but who are unlikely to seek counseling from agencies or telephone services (p. 301).

Cunningham et al. (2002) assessed the effectiveness of a self-help book and a personalized assessment-feedback session, both separately and together, in the general population. Personalized assessment feedback (PAF) interventions are designed to increase motivation for change by providing normative feedback to individuals regarding their alcohol consumption compared with the alcohol consumption of others (heavy drinkers typically overestimate the consumption of others). The study found that at a 6-month follow-up, the combination of self-help book, and PAF had significantly improved drinking outcomes. However, research utilizing bibliotherapy for alcohol problems is mixed, and longer follow-up periods may be necessary to determine the effectiveness of these interventions.

Smoking

An estimated 20.9% (45.1 million) of adults in the United States are smokers (CDC, 2005). The research to date utilizing bibliotherapy for smoking cessation has indicated that bibliotherapy alone may not be effective but may become more effective when used as an adjunct to other modes of therapy. In a review of 60 randomized trials of different forms of self-help materials for smoking cessations, Lancaster and Stead (2006) concluded that self-help materials tailored to the individual may increase quit rates compared with no intervention, but the effect is likely to be small. The authors did not find any additional benefit gained when self-help was used in conjunction with other interventions such as advice from a professional or nicotine replacement therapy.

Curry et al. (2003) also studied self-administered treatments for smoking cessation. They found that there was no evidence that self-help manuals alone were effective. However, self-help manuals increase quit rates when combined with personalized adjuncts such as written feedback and outreach telephone counseling. Population-based estimates are that fewer than 5% of smokers use self-help materials, and those that those who do tend to be heavier, more addicted smokers with limited social support and poor health status. These factors may contribute to the limited effectiveness of bibliotherapy in the treatment of nicotine addiction.

Eating Disorders

It is estimated 1.5% of women and 0.5% of men reported having bulimia, and 3.5% of women and 2% of men reported having binge-eating disorder at some point in their lives (Hudson et al., 2007). In a study of a 12-week CBT bibliotherapy for bulimia and binge-eating disorder (Ghaderi, 2006), self-help had a moderate effect on the patients’ eating problems. No significant difference was found between pure self-help and guided self-help. Carter and Fairburn (1998) evaluated a 12-week bibliotherapy study of pure self-help, guided self-help, or a waitlist control condition for binge-eating disorder. In the pure self-help condition, participants were mailed the bibliotherapy materials. Guided self-help involved six to eight 25-minute sessions in which a nonspecialist therapist facilitated the participants in using the bibliotherapy materials. Both pure and guided self-help were effective at reducing binge-eating behavior, and these gains were maintained at a 6-month follow-up. Guided self-help was more potent than pure self-help on many secondary outcomes, and compliance was higher in the guided group (92% read the whole book) versus the pure group (71% read the whole book).

Carter and colleagues (2003) evaluated two unguided self-help books, one cognitive-behavioral and one nonspecific, in the treatment of bulimia nervosa. The results indicated that both self-help conditions produced modest reductions in the primary behavioral symptoms of binge eating and purging for a subgroup of participants. In this study, neither condition was associated with a decrease in general psychopathology such as depression and anxiety. However, Bailer et al. (2004) found that an 18-week guided self-help bibliotherapy for bulimia and an 18-week 1.5 hours per week cognitive-behavioral group therapy conditions were both effective at decreasing binge eating and vomiting frequencies, as well as depressive symptomatology. Self-help had significantly higher remission rates, however, at follow-up than did the CBT condition. Cooper et al. (1996) also found guided self-help to be effective at reducing bulimic episodes. The researchers also found that those who had poorer outcomes or dropped out of treatment were more than twice as likely to have a history of anorexia nervosa and were somewhat more likely to have a personality disorder. Given the notorious difficulty of treating eating disorders and the difficulty in getting eating-disordered individuals to attend treatment, the above studies indicate that bibliotherapy may be a viable treatment option.

Sexual Dysfunction

Sexual dysfunction rates from a national probability sample indicate that 43% of women and 31% of men experience sexual dysfunction (Laumann et al., 1999). Given the feelings of shame or embarrassment that individuals experiencing sexual dysfunction may experience, bibliotherapy would appear to be a prime treatment venue for this problem, van Lankveld et al. (2001) investigated a 10-week bibliotherapeutic intervention for sexual dysfunctions. Males endorsed an improvement in their sexual functioning at both posttreatment and follow-up. Females reported improvement in their sexual functioning at posttreatment, but not at follow-up. Several gains demonstrated at posttreatment eroded at follow-up including complaints about infrequency of sexual interaction and male ratings of distress associated with sexual dysfunction.

In a meta-analysis of bibliotherapy for sexual dysfunctions, van Lankveld (1998) found bibliotherapy to be initially effective for orgasmic disorders, but the gains were generally not maintained at follow-up. van Lankveld also cautioned, as did Rosen (1987), that improper diagnosis could damage the participant’s health and well-being. The studies all examined in this meta-analysis included some sort of pretreatment assessment to exclude individuals with sexual problems for whom the treatment manuals would be inappropriate. Bibliotherapy appears to have demonstrated efficacy in the treatment of sexual dysfunctions. The effectiveness could be improved by having therapist contact to ensure proper diagnosis as well as provide encouragement to engage in follow-up reading to maintain gains.

Meta-analyses

Meta-analyses have also been conducted looking at a range of different psychological problems. In a meta-analysis of bibliotherapy studies by Marrs (1995), the author found that bibliotherapy appeared more effective for certain problem types (assertion training, anxiety, sexual dysfunction) than for others (weight loss, impulse control, and studying problems). Overall, it was found that the amount of therapist contact did not seem to relate to effectiveness, but there was evidence that certain problem types (weight loss and anxiety reduction) responded better with increased therapist contact. Gould and Clum (1993) conducted a meta-analysis of self-help treatment approaches, the majority of which were bibliotherapeutic in nature (audiotape, videotape were also included). The effect size of self-help treatments was nearly as large as therapist-assisted interventions within the same studies. Self-help problems seemed to be most effective with problems associated with skill deficits and diagnostic problems such as fears, depression, headache, and sleep disturbance rather than habit disorders such as smoking, drinking, and overeating. Overall, the research regarding the use of bibliotherapy as an adjunct, as well as a stand-alone treatment, is promising and lends support for its use for a myriad of problems.

KEY PROCESS VARIABLES

Research on bibliotherapy has focused on questions of effectiveness while largely ignoring identification of process variables. Cohen (1994) stated that bibliotherapy is a combination of two poorly researched and understood phenomena: reading and psychotherapy (p. 40). Marrs (1995) noted in his meta-analysis that most of the studies he examined did not include information on potential moderating variables, such as reading ability or education level of the participants, how much the subjects used the bibliotherapy materials, or personality variables of the readers. This problem parallels the state of research in traditional psychotherapy, where mediating and moderating variables have not been clearly demonstrated. For example, Whisman (1993) has observed that even with cognitive therapy for depression, which has been extensively researched and repeatedly found to be efficacious, conclusions regarding mediators of change should be viewed as tentative due to mixed results for the cognitive mediation hypothesis and small-effect sizes across studies for the effects of cognitive therapy on cognitive phenomena (p. 258).

The literature of the 1950s and 1960s defined bibliotherapy as a treatment modality consisting of three main components: Identification, insight, and catharsis (Lenkowsky, 2001). Schrank and Engels (1981) explained that identification involves developing an affiliation with the literature and may lead to perspective taking, which can help readers develop a sense of normalization and validation. Identification may also help readers learn vicariously through the experience of others. Catharsis occurs through vicarious experience and may lead to insight. Insight is the result of readers seeing their own experiences described in the literature. This insight is hoped to allow for positive change in attitude and behavior. Despite the popularity of defining bibliotherapy by these three components, there is no clear data to substantiate them as process variables.

Cohen (1994) interviewed readers of self-materials about how the literature was helpful to them and found some common themes including: Recognition of self, ways of feeling, and ways of knowing. Ways of feeling involved shared experience (normalization), validation, hope, comfort, inspiration, and catharsis. Ways of knowing included understanding (insight) and gathering of information such as specific techniques for dealing with problematic situations. Readers also identified escape functions and seeing bibliotherapy as an alternative form of therapy, likening reading to being in a support group or meeting with a psychotherapist.

While there are no clear conclusions on what variables account for change in bibliotherapy, some studies have shed light on putative process variables. Overall, these studies point to nonspecific processes thought to exist in almost all therapies, variables that may be the ingredients of change in more traditional psychotherapies, and factors specific to bibliotherapy such as amount of therapist contact, content of bibliotherapy, and understanding of reading materials.

Most treatment modalities involve a variety of nonspecific factors which have been linked to treatment outcomes. Frank (1982) noted that these nonspecific process variables include the therapeutic relationship, having a designated healing setting, provision of a rationale for symptoms and an explanation of treatment procedure, and the treatment procedure itself. These factors were thought to remoralize clients and restore hope for clinical improvement. Ilardi and Craighead (1994) proposed that all of Frank’s nonspecific processes could be boiled down to hope. The authors referred to the body of literature supporting placebo effects, stating that such effects were likely due to expectancy effects, or hope. Along these lines, Marrs’ (1995) meta-analysis of bibliotherapies found that studies which used placebo control groups had smaller effect sizes than those using no treatment controls, suggesting that part of the effectiveness of bibliotherapy may be due to expectation