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Self-Help Treatments for Anxiety Disorders

Abstract and Keywords

This chapter considers the effectiveness of self-administered treatments for anxiety—media-based approaches such as manuals, self-help books, audiotapes, computer programs, and Internet sites that allow individuals to help themselves with minimal therapist contact. Systematic and meta-analytic reviews of traditional self-administered treatments or bibliotherapy suggest that in research settings these interventions produce encouraging medium-effect sizes that are smaller than therapist-guided interventions. Web-based treatment, provided through the Internet, has the potential for very wide reach. Some degree of therapist contact during self-administered treatments is related to larger effect sizes, suggesting that therapist monitoring may increase engagement in treatment. Research is needed on approaches to recruitment, screening, increasing engagement, and evaluating the cost of programs.

Keywords: anxiety, bibliotherapy, minimum therapist contact, self-administered treatment, self-help, Web-based treatment

For the purposes of this chapter, self-help treatments are defined as media-based approaches such as manuals, self-help books, audiotapes, computer programs, and Internet sites that allow individuals to help themselves with minimal assistance from a health service provider (Williams, 2003). We will not address the use of self-help groups because there is much less research available in this area (den Boer, Wiersma, & van den Bosch, 2004), even though this is a growing source of assistance for a wide range of health problems (Eisenberg et al., 1998). Instead, we will consider the naturalistic use of self-help treatments, evidence of their effectiveness, and ethical concerns.

A key factor in the interest in self-help approaches is the high level of need in the community. The majority of people with anxiety and depressive disorders do not receive care (Wang, Lane, et al., 2005) and there are long delays before people seek and receive care (Wang, Berglund, et al., 2005). Among those who do receive care, the care is often inadequate (Wang, Lane, et al., 2005). In a large epidemiological study of the mental health of Canadians age 15 years and over (n= 36,816), 8.7% of respondents indicated that they had seen a professional of some kind about their emotions, mental health, or use of alcohol or drugs in the previous 12 months (Sareen, Cox, Afifi, Clara, & Yu, 2005). A further 3% reported that in the previous 12 months there was a time when they needed help for these concerns but did not receive it. Among this group with perceived need for help but no help-seeking, the three types of care most commonly desired were “therapy or counselling” (50%), “help for personal relationships” (22%), and “information on mental illness or treatment” (20%). Only 8% of this subgroup indicated that they wanted medication treatment. The three most common reasons for not (p. 489) seeking care were “preferred to manage [emotional problems] by self” (35%), “did not get around to it” (19%), and “did not know how to get help” (16%). The large proportions among those with a perceived need for care who prefer to manage the problem by themselves, desire information, or do not know how to get help suggest that there are many people who may be receptive to self-help approaches.

Self-help interventions are considered because they may increase the availability and accessibility of help (allowing interventions to be used at convenient times and at home), reduce costs to consumers and the health care system, increase sense of privacy relative to the use of traditional services (where stigma is an issue for many consumers), and increase the consumer's control over (of) the intervention (Griffiths, Lindenmeyer, Powell, Lowe, & Thorogood, 2006; Proudfoot, 2004).

Naturalistic Use of Self-Help Treatments

Controlled studies of self-help treatments typically recruit participants through media advertising or notices in health care settings. Participants are evaluated for the presence of the problem under investigation, symptom severity, and suitability for participation in the study. Newman, Erickson, Przeworski, and Dzus 2003 point out that there is a great deal of variability among controlled trials in the amount of therapist contact. They suggest four categories to describe therapist contact:

  1. 1. self-administered therapy (therapist contact forassessment at most)

  2. 2. predominantly self-help (therapist contact beyond assessment is for providing the initial therapeutic rationale and/or for periodic check-ins)

  3. 3. minimal-contact therapy (active involvement of a therapist in directing the intervention but to a lesser degree than traditional therapy)

  4. 4. predominantly therapist-administered treatments (regular contact with a therapist for a typical number of sessions with self-help materials used to augment standard therapy)

In the naturalistic use of self-help treatments, there is a similar range of therapist involvement from situations in which the consumer uses material with no therapist contact to situations in which the therapist uses self-help materials to augment therapy sessions. The most widely available and evaluated form of self-help treatment involves the use of traditional text materials. Most bookstores have a large section devoted to self-improvement and self-help approaches for a wide range of problems. There is no contact with a therapist and consumers evaluate for themselves whether there is a good match between the program and their needs.

Many professionals recommend self-help books as part of their practice. Norcross 2000 provides data from surveys mailed to members of the American Psychological Association Clinical and Counselling Divisions. Self-help books were recommended by 85% of psychologists to an average of 34% of their clients. Clinicians rated many of the resources that are available positively and very few indicated that they felt self-help materials had a harmful effect on their clients. The potential positive impact of the use of high-quality self-help materials is illustrated in a study involving the treatment of panic disorder. Clark et al. 1999 found that they could reduce therapist time from over 12 hours to 6.5 hours with the use of self-study modules with no loss in treatment effectiveness.

In recent years, formats have been developed that take advantage of new technologies. Table 1 describes some of the advantages and challenges associated with the commonly available formats. The most widely available new technology at this point is the Internet (Proudfoot, 2004). An increasing proportion of households throughout the developed and developing world have access to this technology and the Internet is widely used as a source of health information. For example, Sirovatka 2002 reports that 7 million hits are registered every month on the National Institute of Mental Health (NIMH) homepage.

A colorful description of the wide availability of self-help resources is provided by Norcross 2000: “The self-help market resembles a Persian bazaar with proliferating choices and no clear answers: should you nurture others or nurture your “inner child”; seek success or simplicity; just say no or just do it; confront your fears or honor them. Sorely needed is research on the utility and quality of self-help materials” (p. 373).

Reviews of the Effectiveness of Self-Help Treatments

Systematic Review

Newman et al. 2003 describe the results of a systematic review of self-help interventions for anxiety disorders, focusing particularly on the degree of therapist involvement. In examining study methodology, they noted that it was often difficult to make comparisons among studies because they were not clear in specifying the amount of therapist involvement, the cost of the intervention, and the degree to which participants implemented various (p. 490) components of the intervention. The programs used diverse materials and it was difficult to determine the quality of the materials. Few studies evaluated the therapeutic alliance, an important factor in the effectiveness of psychological interventions.

Table 1. Advantages and Challenges of Different Approaches to Disseminating Self-Help Interventions

Format

Advantages

Challenges

Limited-production text materials

• Material may be focused on local concerns and resources

• Time-consuming to produce and keep up-to-date

• No computer resources required

• Limited distribution

• Cost of materials

• Space required for inventory

Commercially available books

• Existing distribution system through bookstores and Internet

• Challenge to become familiar with materials on a wide range of topics

• Current availability of a wide range of materials

• Quality of materials and reading level varies

• More difficult to tailor the program to the needs of the client

Computer-based programs (e.g., CD)

• Easier to control copying of materials

• Computer and printer access is required

• Modest cost to client

• Younger people are more familiar with this format, older people are often less familiar

• Programs may be interactive and branching to respond to the needs and interests of different clients

• Challenging to find an economic model to recover the cost of production and dissemination

• May include some audio and video material

• High initial development costs

• Limited availability of programs

Internet-based programs

• Very widely distributed (internationally)

• Computer, printer, and Internet access is required

• Content may be modified or expanded easily

• Younger people are more familiar with this format, older people are often less familiar

• Modest or no cost to client

• Challenging to find an economic model to recover the cost of production and dissemination

• Programs may be interactive and branching to respond to the needs and interests of different clients

• Variable quality in publicly available material

May include some audio and video material

• High initial development costs

• Development tools are available in many health and educational settings

• Some good examples are currently available

The review suggested a number of conclusions related to the degree of therapist involvement in the treatment. For many of the anxiety disorders, there were not enough studies of self-help interventions to draw firm conclusions. The findings indicate that self-administered therapy for specific phobia led to more improvement than no treatment and placebo control groups and outcomes were not significantly different from interventions with greater therapist contact. Therapy was more likely to be effective when participants found the self-help tool to be credible and when they were highly motivated for treatment. Self-administered treatment provided in the research clinic setting was generally more effective than the same intervention applied at home, suggesting that some degree of accountability and monitoring had a positive effect on outcome.

(p. 491) Considering predominantly self-help interventions, they found that for panic disorder, specific phobia, and mixed anxiety samples, approaches that emphasized in-vivo exposure were superior to no treatment and equivalent to interventions that involved greater therapist contact. For minimal-contact therapy, outcome was similar to more intensive treatments for specific phobia, panic disorder (without severe agoraphobia), mixed anxiety samples, and social phobia.

Meta-Analytic Reviews

There are a number of meta-analytic reviews that focus on the effectiveness of self-help treatments. Early meta-analytic studies suggested that self-help approaches may be particularly helpful with anxiety problems (Gould & Clum, 1993; Marrs, 1995) in comparison to habit problems such as smoking, excessive drinking, and weight problems. Other reviews suggested that self-help approaches might rival therapist-directed interventions in terms of magnitude of effect (den Boer et al., 2004; Gould & Clum, 1993; Marrs, 1995; Scogin, Bynum, Stephens, & Calhoon, 1990). Hirai and Clum 2006 report a meta-analysis summarizing 33 randomized controlled trials of self-help treatments for anxiety problems. Most of these studies used traditional text materials. The largest number of studies focused on panic disorder (8), social anxiety disorder (7), and specific phobia (4) while there were few studies of generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), test anxiety, and mixed anxiety. They found that the dropout rate in these studies of 12% during the intervention and 9% by the follow-up assessment was similar to the rate in control groups and therapist-directed interventions. The mean effect size for the self-help interventions (calculated using Cohen's d) was.68 compared to waiting list controls and.50 compared to placebo controls. The effect size compared to therapist-directed interventions (-.42) indicated that the therapist-directed interventions produced larger changes in anxiety. The follow-up data available were typically for short periods (1 to 4 months) but suggested reasonable maintenance of gains. Therapist contact during the intervention was related to larger effect size, although the amount and type of therapist contact was not related, suggesting that minimal therapist contact may be enough to increase the effectiveness of self-help treatments. There were some differences in effect size related to diagnosis, suggesting that self-administered treatments were particularly effective with panic disorder. The authors concluded that there is good support for the effectiveness of self-administered treatments. These treatments generally produce a medium effect size, which is smaller than the effect size of therapist-directed treatment for most problems. This material is also well suited for use in stepped care approaches.

Recent Studies of Self-Help Treatments

Traditional Text Material

In a particularly informative study, Febbraro, Clum, Roodman, and Wright (1999) compared two forms of bibliotherapy with no therapist contact (bibliotherapy alone or bibliotherapy with daily self-monitoring and self-administered feedback) to two control procedures (waiting list or daily self-monitoring and self-administered feedback). All four groups showed similar improvement over time with no additional effect of bibliotherapy. In comparing these results to previous findings, the authors suggested that a key factor may have been the lack of therapist contact for the initial assessment (done by mail in this study) and during the course of the study. Previous studies with positive findings had involved some degree of therapist contact during the assessment and/or intervention. In a follow-up phase to this study, the authors found that participants who entered a 6-month relapse prevention phase with a relapse prevention manual and monthly therapist telephone contacts (up to 15 minutes) had a better outcome on panic measures than participants with no relapse prevention contacts (Wright, Clum, Roodman, & Febbraro, 2000).

A research team from the University of Manchester in England recently evaluated the use of a self-help cognitive behavioral therapy (CBT) program for patients referred from primary care with anxiety or depression. Patients expressed satisfaction with the materials but the degree of improvement with the self-help program was no greater than for treatment as usual when it was used independently after assessment (Fletcher, Lovell, Bower, Campbell, & Dickens, 2005) or with additional meetings with a therapist (Mead et al., 2005).

In a study of the treatment of PTSD following motor vehicle accidents, Ehlers et al. 2003 compared three interventions: a self-help treatment booklet using CBT principles (with a 40-minute introduction by a therapist), repeated clinician assessments, and individual CBT (average of 12 sessions). Individual treatment was much more effective than the other two conditions. The use of the booklet did not produce results superior to the repeated assessment condition.

(p. 492) In one of the few studies focused on children's anxiety, Rapee, Abbott, and Lyneham 2006 compared bibliotherapy to group intervention to a waiting list control condition to teach CBT principles to parents of anxious children. Pre-, post-, and follow-up assessments took place in person but there was no therapist contact in the bibliotherapy condition (or the waiting list condition) during the treatment phase. The dropout rate was twice as high in the bibliotherapy condition (32%) as in the group (16%) and waiting list conditions (14%). There was more improvement in the bibliotherapy condition than in the waiting list condition but less than in the group intervention condition. In the intent-to-treat analysis, the proportion no longer meeting the criteria for any anxiety disorder was approximately 6% in the waiting list condition, 18% in the bibliotherapy condition, and 49% in the group intervention condition. Lyneham and Rapee 2006 evaluated the use of the same bibliotherapy program for parents of anxious children in rural communities with differing forms of therapist support, including scheduled telephone calls, scheduled e-mail contacts and replies, and client-initiated telephone calls (if help was required). Initial and subsequent assessments were completed by using a telephone interview and a questionnaire package returned by mail. Following treatment, the percentage of children no longer meeting criteria for an anxiety disorder was 79% in the scheduled telephone contact condition, 33% in the e-mail condition, 31% in the client-initiated telephone contact condition, and 0% in the waiting list condition. Those in the scheduled telephone contact condition completed an average of 8.3 of the 9 planned telephone contacts with an average duration of 25 minutes. In contrast, only about 30% of those in the client-initiated telephone call condition initiated contacts, with most of these only making one call. At 12-month follow-up these gains were maintained or extended. This study illustrates the dramatic differences in the results of self-help intervention based on the amount of therapeutic contact and the method of contact.

Audio Materials

A few self-help programs such as the Attacking Anxiety program available through the Midwest Center for Stress and Anxiety in Ohio are marketed directly to consumers through infomercials and widely advertised public meetings. A naturalistic study of this program, which relies on audiotapes and text material, by independent assessors suggested that 35% of respondents achieved clinically significant improvement, a further 23% achieved reliable change, and only 1 of 176 reported negative change (Finch, Lambert, & Brown, 2000). The authors noted that this assessment was based on the one-third of program participants who returned evaluation questionnaires.

Internet Programs

Due to the advantages of Internet-based programs (see Table 1), this approach has supplanted most earlier programs developed for use with desktop computers. Most studies of Web-based programs involve participants who are screened and then referred to the program. Participants may use a password to have access to the program and may be required to complete modules sequentially. In some cases, they are required to complete assessments and even demonstrate some level of knowledge before moving on to the next module. In openly available programs, in contrast, participants find the program on the Internet, they may complete some self-assessment materials, and then they may use the program freely. Participants may attempt some or all of the modules, print or save some of the material, and may return to the site multiple times.

Limited Access Internet Programs

One of the pioneering programs in this area is the FearFighter program, first developed as a computer-based program and later modified for use on the Internet. While the program is currently being employed in a number of primary care settings in the United Kingdom, the only large-scale evaluation was carried out in a specialty mental health clinic (Marks, Kenwright, McDonough, Whittaker, & Mataix-Cols, 2004). Individuals with agoraphobia, social phobia, or specific phobia were assigned to the computer-guided self-exposure program (FearFighter, n = 37), clinician-guided self-exposure (n = 39), and a computer-and audiotape-guided relaxation program (n = 17). The relaxation program had a significantly lower dropout rate (6%) than FearFighter (43%) and the clinician-guided programs (24%), which did not differ significantly from each other. Considering only treatment completers, the two self-exposure conditions had comparable improvement and satisfaction at posttreatment assessment, while the relaxation condition showed little clinical improvement in phobic avoidance. Including both completers and dropouts, average therapist contact time was 76 minutes in the computer-guided relaxation program, 76 minutes in the FearFighter program, and 283 minutes in the (p. 493) clinician-guided program. Schneider, Mataix-Cols, Marks, and Bechofen 2005 evaluated two different programs for treatment of panic and phobic anxiety (agoraphobia with or without panic disorder, social phobia, or specific phobia) provided on the Internet after participants were screened by telephone for the study. The FearFighter program, which emphasizes exposure to feared situations, was compared to the Managing Anxiety program, which emphasizes relaxation and cognitive change with no encouragement or discouragement of exposure. The two programs produced equivalent results at the end of a 10-week treatment period, but by the time of the 1-month follow-up, the exposure program produced greater improvement on 5 of 10 measures. Total telephone contact time during the treatment phase was 115 minutes for the FearFighter program and 87 minutes for the Managing Anxiety program. While this study did not have a control condition, the magnitude of change was similar to that found with active treatments and was considerably larger than the changes measured in control groups in previous studies.

Carlbring, Ekselius, and Andersson (2003) describe a study of two Internet interventions for panic disorder. In this minimal-contact therapy approach, participants received a 6-module CBT program or a 9-module applied relaxation program. Therapist contact consisted of an in-person diagnostic interview and e-mail contact. The amount of therapist time for contact during the treatment was reduced from an earlier stage of development of the program by using a library of standard e-mail answers to questions from participants. Within group effect size (d) was 0.71 for applied relaxation and 0.42 for CBT. This study had weaker results for the CBT program than a previous study by this group, possibly because of more impersonal e-mail contact, slower response time to e-mail contacts (7 days versus 1 day), and no deadlines for completing modules. Carlbring et al. 2005 extended this study by comparing a 10-session Internet CBT program to 10 sessions of individual therapy for panic disorder. To increase social interaction, the participants were required to post at least one message in an online discussion group about a predetermined topic in every module. A supportive atmosphere developed as participants were able to read and comment on messages. In addition to submitting homework, which was used to determine whether the participants could go on to the next session (feedback was given within 36 hours), participants were free to submit as many messages as they wanted to the therapist. The mean time spent on administration and responding to the e-mails was 2.5 hours for each participant. The within-group effect size (d) for the Internet treatment (0.80) was very close to that for the individual CBT condition (0.93). Carlbring, Furmark, Steczko, Ekselius, and Andersson (2006) describe an open trial of Web-based treatment of social anxiety disorder using similar methodology. Therapist contact, an average of 3 hours for each participant, was provided by e-mail and an online discussion group was provided as well. The intervention had a within group effect size of 0.88 at posttreatment and improved at a 6-month follow-up to 1.31.

Klein, Richards, and Austin (2006) compared therapist-assisted self-help using either a manual or an Internet program for panic disorder. Both groups showed considerable improvement in comparison to an information-only control group. The Internet intervention was more effective than the CBT manual in reducing clinician-rated agoraphobia and number of general practitioner (GP) visits at postassessment. Both groups received a considerable amount of therapist assistance, via telephone for the manual group (with a once weekly call for a total of 4 hours) and via e-mail for the Internet group (response within 24 hours for an average of 5.5 hours). Satisfaction and treatment credibility were equally high for both groups. Participants tended to complete the treatment in fewer days in the Internet program than in the manual program (45 versus 63 days). The authors suggested that the differences between the two conditions may have been due in part to the faster response provided by e-mail as compared to scheduled weekly telephone contacts.

Lange et al. 2003 describe an interesting approach to the treatment of traumatic stress in clients recruited through the media and a Web site. Screening and assessments were carried out on an Internet site. The treatment involved 10 45-minute writing assignments over 5 weeks. The assignments covered three general themes: “self confrontation” (or exposure), cognitive reappraisal, and “sharing and farewell” (to encourage a symbolic letting go of the event). Assignments were submitted through the Web site and written feedback was provided via the Web site within 24 hours by trained graduate students. Completers in the active treatment showed an impressive proportion with clinically significant improvement (45%–50%) compared to the waiting-list control group (8%). The attrition rate was high with 437 participants being screened positive for participation but only 184 returning the consent form by mail and being randomized to (p. 494) either the treatment or waiting-list control conditions. Of the 122 assigned to the treatment condition, 24 dropped out during the self-confrontation phase (20%), 11 during the cognitive restructuring phase (9%), 9 during the social sharing phase (7%), and 9 did not complete the postassessment (7%). Of the 62 assigned to the control condition, 30 did not complete the postassessment (48%). A proportion of those who dropped out were successfully contacted with a questionnaire about reasons for dropping out. Common reasons for dropping out were difficulties with the computer and network (40%), a preference to see a therapist in person (30%), and discomfort about writing about personal events (30%). No information was provided about the amount of therapists' time involved in this program.

Hirai and Clum 2005 describe a small Internet-based intervention for persons with traumatic event related distress. Participants were recruited from college programs and the community and were screened by mail. An 8-week self-help program produced significant reductions in symptoms compared to a waiting-list control group. There was no direct or e-mail contact with therapists except for reminders to complete assessments and encouragement to complete the program within the fixed time period. The dropout rate was 25%. On a measure of anxiety, 54% in the Internet group and 7% in the control group showed clinically significant improvement. This study suggests that an Internet program may be helpful for individuals who have experienced traumatic events and are experiencing significant distress.

Open Access Internet Programs

There are a number of self-help programs that are widely available on the Internet. Two programs focusing on anxiety are www.Paniccenter.net for panic and www.anxieties.com with brief self-help resources for a range of anxiety disorders. One of the most well developed Web-based programs is www.MySelfHelp.com with modules for depression, grief, insomnia, eating disorders, compulsive shopping, guilt, self-esteem, helping loved ones, and stress management (Bedrosian, 2004). The program is designed as a tool to complement work with a health service provider, although it may also be used as a freestanding service. Providers are encouraged to refer patients to the Web site and in turn participants are encouraged to share summary information about their participation in the program with the health care provider. The program has been the focus of extensive input by mental health specialists but has no published evaluations.

Farvolden, Denisoff, Selby, Bagby, and Rudy (2005) describe the pattern of usage and outcome data available from www.Paniccenter.net. Over a 17-month period there were 484,695 visits and 1,148,097 page views from 99,695 users of the site. Persons who wanted to use the self-help program aspect of the site were required to register and 1,161 users did so. Of these, 1,059 chose to download the self-help manual. The program was organized into 12 sessions. There was very high attrition from the structured program and only 12 registered users completed all of the 12 sessions. The authors note that some of the users may have worked with the downloaded program and others may have used the program in a nonlinear manner. Considering the larger group of participants who participated in the first part of the program, there was a significant reduction in frequency of panic attacks between Sessions 2 and 3.

Christensen, Griffiths, Korten, Brittliffe, and Groves (2004) evaluated a CBT Web site focused on prevention of depression (called MoodGYM). They compared spontaneous users and persons referred as part of a clinical trial. This study provides a helpful comparison with the study by Farvolden et al. 2005. During the 29-month period covered by the study, 19,607 visitors registered on the site. Of these, 62% completed at least one set of assessment scales but only 16% completed at least 2 of the 5 modules. This compared to 86% of trial participants who completed one set of assessments and 67% who completed 2. There was more attrition by module 4, completed by 1.4% of spontaneous users and 38% of trial users. Spontaneous and trial users reported similar initial levels of depression, well above community norms, and for both groups there were equivalent decreases in depression scores with an increasing number of treatment modules completed. The major difference between the groups was the very high rate of attrition among spontaneous users.

Ethical Concerns About Self-Administered Treatments

Gerald Rosen has expressed concerns for many years about the proliferation of self-help books and excessive claims about their effectiveness in the absence of research evaluating the programs. Recent reviews by Rosen and his colleagues suggest that the dissemination of self-help programs has increased tremendously over the years without a corresponding increase in the proportion that have been evaluated (p. 495) (Rosen, 1993; Rosen, Glasgow, & Moore, 2003). Rosen provides examples of situations in which treatment manuals have a reasonable level of effectiveness when used with therapist supervision but are not used successfully by most people in unsupervised use. Small changes in procedures may have major effects on program effectiveness. Rosen et al. (2003) suggest a very useful framework for evaluating self-help programs. There is also concern that unsuccessful use of self-help materials may have a negative effect (Rosen, Glasgow, & Moore, 2003). The issue of negative effects of self-help programs has been addressed by a small number of researchers. Scogin et al. (1996) reviewed five studies of treatment of depression using a widely available self-help book and found that there was no evidence that more people experienced a worsening of the problem with depression than in therapist-administered treatments. The number of participants experiencing deterioration was low, especially in comparison to the number experiencing improvement.

Summary and Conclusions

Self-help treatments continue to be widely accepted and used by the public, and self-help resources are often used by clinicians in the field. There are exciting new developments of self-help treatments provided through the Internet. At the same time, systematic reviews and individual studies suggest that there continues to be limited scientific support for the effectiveness of self-help programs when they are used completely independently. The degree of change produced by these programs when they are effective is modest. On the other hand, there is strong evidence that increasing the amount of contact with a therapist increases the effectiveness of self-help programs and produces results that may be similar to programs requiring considerably more therapist time. Given the promise of self-help treatments for increasing the availability and accessibility of services and reducing costs, it is clear that more work on the development of effective programs is warranted. Some of the important factors to evaluate in future research include methods of recruiting participants, approaches to screening and facilitating entry to the program, engagement in the program, contact during the program to encourage participation, follow-up after the program, and cost of the program relative to alternatives.

Richardson and Richards 2006 suggest that it may be possible to improve the effectiveness of programs by paying more attention in the development of self-help materials to common factors that have been studied in psychotherapy. They argue that it may be possible to write materials in ways that increase engagement and the therapeutic alliance, communicate empathy and warmth, provide responsiveness and flexibility, and deal with problems that develop in the course of therapy. The addition of online discussion groups such as the one described by Carlbring et al. 2005 may increase engagement in treatment. Clearly, more study of the process of self-help treatment and involvement in different aspects of treatment may provide information that will assist in improving treatments.

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