Sam is now working and he feels that he no longer needs to be regularly engaged with rehabilitation services. His GP prescribes his medication and Sam knows that he can turn to her if he is in real difficulty. He is, however, aware that he remains susceptible to difficulties – especially symptoms of depression and anxiety and the temptation to drink too much when he is under stress. He would like to be able to access some kind of support or assistance without having to be a regular client of a mental health service.

There is a huge range of self-help resources available to support people to achieve better mental health. Perhaps the best known and most common are self-help books. However, self-help resources include autobiographies, movies, self-help support groups (e.g. AA) and internet materials ranging from information through to cognitive-behavioural therapy (CBT) treatment programmes. The problem with having so many possible self-help resources for a practitioner supporting people in recovery is deciding which to recommend. There are literally tens of thousands of books in the self-help arena and it is estimated that thousands of new self-help books are published each year.

The aim of this chapter is to help mental health workers support people with mental illness through the use of self-help resources. The focus of this chapter is on the use of books (bibliotherapy) and internet self-help programmes with demonstrated effectiveness.

There are several broad steps in the process of supporting people in their use of self-help materials.

1. Clarifying the specific need and context for self-help

2. Identifying appropriate self-help resources

3. Supporting the person in accessing and using the resources

4. Evaluating the effectiveness of the self-help programme

Step 1: Clarify the need for and context of self-help

The advantages of bibliotherapy and internet self-help are that the person can complete them in their own home without necessarily incurring the costs associated with seeing a professional in terms of time and fees. Individuals living in rural areas can have particular difficulty in accessing appropriate care (Griffiths & Christensen, 2007). Others prefer self-help over professional help due to the stigma associated with professional mental health help seeking. There are many reasons why individuals may prefer and seek self-help approaches to their problems.

Understanding when to use a self-help resource depends on the problems the individual is experiencing and the target for change (e.g. knowledge, attitudes, symptoms), the available research evidence supporting their use (to be covered in more detail in the section below) and broader environmental and treatment context issues (stepped care, adjunct to current treatment or access to the internet, etc.). There are some problem domains where self-help programmes have more evidence than others (e.g. bibliotherapy for depression and anxiety; Den Boer et al., 2004).

In what domain does the person need help?

The initial consideration is the domain in which the person needs help and whether there is likely to be an appropriately effective resource. Try to clearly identify the problem domain and likely target. Domains for which there is some research support are listed below in the sections on ‘Professional and Expert Consensus’ and ‘Effectiveness’. Likely targets broadly refer to improvements in knowledge, attitudes (such as reductions in perceived stigma), behaviours (increasing exercise or decreasing sugar intake) or more traditional reductions in symptom severity. Some interventions in specific problem domains (e.g. internet treatment of depression) have more reliable effects in some target outcome areas (e.g. knowledge).

Assess the client’s prior self-help experiences

Norcross (2006) makes a number of recommendations for integrating self-help into therapy. One is to assess the clients’ prior self-help experiences. This will help clarify those things clients have found previously helpful, whether they can understand and adhere to the tasks and what has changed since their last use of self-help. Changes since last attempts will help focus goals for future self-help material.

Be familiar with the self-help resources and tailor selection

Almost all evidence-based self-help bibliotherapy has involved some level of brief support from a therapist or trained paraprofessional. The amount of support is dependent on how difficult the material is and this highlights the need for clinicians to have at least some familiarity with the self-help material before recommending it.

This familiarity also increases the potential to tailor the selection of material taking into account the individual needs of the person (Norcross, 2006). Part of this tailoring process depends on contextual issues around the use of self-help. For example, increasingly self-help is being recommended as part of what is termed ‘stepped care’.

Context of treatment delivery

Stepped care broadly involves providing the ‘least restrictive’ care available that is likely to produce significant health gains. The term ’least restrictive’ in this context usually refers to the lowest impact on patients with regard to cost and inconvenience, but also the minimum amount of treatment provider (therapist) time (Bower & Gilbody, 2005; Salloum, 2010; Tolin et al., 2011). A stepped care model would encourage the use of self-help approaches as first-line treatment before stepping up care to more intensive treatments if improvement does not occur.

It has been suggested that self-help resources might be used while someone is on a waiting list to be seen for professional services. It has been argued that potentially, some individuals will improve and those that don’t may be more motivated for face-to-face treatment with a professional (Norcross, 2006). However, a trial of guided self-help for a group of 114 patients awaiting psychological therapy for depression and anxiety failed to find any additional benefit compared to patients who were on the waiting list and received no self-help intervention (Mead et al., 2005). Patients were satisfied with the intervention and whether that provides additional motivation or benefits when receiving professional services is yet to be determined.

Self-help might be used as a supplement when the main focus of face-to-face treatment is on other problem areas or disorder-specific needs. Campbell and Smith (2003) distinguish between bibliotherapy for clinical use versus support/informational use. Clinical use refers to using bibliotherapy with a focus on a clinical condition such as depression. In this circumstance bibliotherapy is often integrated with face-to-face treatment and is usually more closely monitored during these sessions. When bibliotherapy is used for more support or informational purposes the target is not central to the clinical condition – for example, parenting or dealing with chronic illness of a loved one.

The focus of this chapter is more on the clinical use of bibliotherapy. Part of this process involves identifying appropriate evidence-based self-help resources and monitoring treatment response to determine whether further, more intensive treatment is needed in the future.

Step 2: Identifying appropriate self-help resources

There are two primary methods for identifying appropriate self-help resources. The first and preferable method involves consideration of empirical research on their effectiveness. The second occurs when research is not available for particular resources and this relies on professional consensus, usually as a result of surveys of practising mental health professionals or experts.

Effectiveness studies

A broad review of 38 self-help interventions for depression has been undertaken and highlights the wide range of self-help interventions for some mental health problems but found evidence of efficacy for less than a third (Morgan & Jorm, 2008). Examples of interventions with some efficacy included bibliotherapy, computerised interventions, distraction, relaxation training, exercise and pleasant activities. Many of these interventions form components of self-help contained in multicomponent bibliotherapy approaches.

Effectiveness studies have found many biblotherapy treatments helpful for a range of problems including depression (Gregory et al., 2004; Morgan & Jorm, 2008), anxiety (Van Boeijen et al., 2005), alcohol problems (Apodaca & Miller, 2003) and sexual dysfunctions (Van Lankveld, 1998). The mean effect size of bibliotherapy self-help for anxiety and/or depressive disorders in randomised controlled trials is considered moderate to large when compared to placebo or no treatment control groups (e.g. Cuijpers, 1997; Den Boer et al., 2004). Bibliotherapy may be as effective as professional treatment of relatively short duration (Den Boer et al., 2004).

In other problem areas there are promising findings, but more research is needed to strengthen statements of effectiveness (e.g. hypochondriasis: Buwalda & Bouman, 2009; panic disorder: Nordin et al., 2010; tinnitus-related distress: Malouff et al., 2010; parenting: Forehand et al., 2010).

Unfortunately, not all of the effective books or written materials that were used in this research are readily available and access to ’self-help manuals’ may be difficult. However, many of the books recommended by professional or expert consensus can be purchased through book stores and many of these also have some degree of research evidence.

Professional and expert consensus

Some guides offer help in the process of selecting appropriate self-help materials, such as the Authoritative Guide to Self-Help Resources in Mental Health (Norcross et al., 2000). This guide is based on the results of five national studies in the USA involving surveys of clinical and counselling psychologists. More than 2500 psychologists contributed by rating self-help resources in 28 categories (e.g. anger, anxiety, schizophrenia) on a five-point scale from ‘Extremely good’ to ‘Extremely bad’. The result is a listing of recommendations using a five-star rating system for a wide range of self-help resources including self-help books (bibliotherapy), autobiographies, movies, internet resources and self-help/support groups. The surveys have not been updated since the 1990s when these data were collected. Still, many of these books are likely to be readily available.

Below are the 10 top-rated self-help books related to mental health problems from Norcross et al. (2000).

1. Skills Training Manual for Treating Borderline Personality Disorder (Linehan M)

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