Synonyms

Bibliotherapy; Self-administered treatment; Self-help

Definition

The formal implementation of written or digital materials to facilitate understanding or assist in efforts relevant to a person’s developmental or therapeutic needs.

General Overview

In its simplest form, bibliotherapy uses literature to facilitate improvements in the well-being or functioning of an individual or group of individuals. The literature may be instructional in nature (i.e., a therapeutic manual written in narrative to aid the client in self-administered treatment) or conceptual (i.e., a fictional or autobiographical piece which illustrates issues and/or dealings related to the reader’s problem of interest). Through the years, the media of bibliotherapy has broadened. Electronic and auditory formats are often available to the public; websites, handouts, and even smartphone applications have been developed to present material. The role of the psychotherapist in bibliotherapy may vary as well (i.e., completely self-administered, therapist guided, therapist administered). The following entry will outline the basic principles and concepts associated with bibliotherapy and related forms of self-help, discuss current modes of distribution and application, and, finally, review the general state of bibliotherapeutic endeavors in older adult populations and outline future directions.

The general purpose has remained the same despite the varied formats in which bibliotherapy may appear and be administered: to facilitate the participant’s consideration and understanding of the problem of interest and to encourage beneficial change in knowledge, perspective, and application of skills. Bibliotherapy has been defined as the use of written material: “…for the purpose of gaining understanding or solving problems relevant to a person’s developmental or therapeutic needs” (Marrs 1995). In current application, and for the purposes of this entry, this definition can be extended to include media-based products (e.g., DVDs, audio files, community websites).

Concepts, Principles, and Modalities of Self-Help

In many cases in which bibliotherapy is recommended, it provides a portable venue in which therapeutic change may occur both inside and outside the therapeutic setting. Difficult to access populations (e.g., mobility-restricted persons, prison populations) may benefit from this more transportable and time-flexible approach. Furthermore, bibliotherapy may provide a foot in the door technique to facilitate a change in one’s attitude toward seeking mental health treatment. Those who are unsure of the merits of psychological treatment or hold negative or ambivalent feelings toward mental health treatment may find themselves more open to seeking treatment if given a tangible medium of treatment that they can evaluate and reevaluate at their leisure. This, of course, assumes the recommended self-help material is sound and plausible. Bibliotherapy may also provide anecdotal material to stimulate and direct discussion in group or social settings. For instance, it may be less threatening to talk about an issue embedded in the struggles of a literary character or relevant problem portrayed by the interaction of individuals in a written, spoken, or filmed illustrative example. Reading about others with similar experiences may also decrease feelings of social isolation and promote healthy perspective taking.

Openness to psychotherapy varies as a function of many factors, including one’s cohort. The issues faced by older adults may also vary, and physical and geographical access to individuals struggling through similar situations may be limited. In summary, bibliotherapy presents a form of psychological treatment that is easily distributed and is often more financially accessible. It can be retained as a useful resource to refer back to, can help connect older adults with others who share similar experiences, and allows the individual to dictate the pace and frequency in which they approach psychological change.

Varying Levels of Administration

The overarching principle of psychologically based self-help programs such as bibliotherapy is that, for some problems, consumers may be able to implement treatments with little or no professional assistance. The goals of psychotherapy and bibliotherapy are generally the same. The difference is largely in the degree to which professional involvement is included in treatment. One conceptualization has been that professional involvement exists on a continuum. This continuum ranges from traditional psychotherapist-administered psychotherapy (with no self-help augmentation) to entirely self-administered treatment (typified by the purchase of written or DVD materials that are implemented with no therapist assistance). Most of the evidence-bases exist around the midpoint of this continuum and are concerned with the effects of minimal-contact or guided self-help and therapist-administered self-help (defined further below).

Though the categorical definitions of self-help can vary, three broad categories are likely the most common descriptive derivations in use today (Glasgow and Rosen 1978). Varying in the degree of professional, or colloquially stated, therapist assistance, these three categories outline important aspects of bibliotherapeutic delivery and are therefore useful keywords to implement when searching for, or publishing, research in this area. In therapist-administered self-help, the psychotherapist or trained professional plays their most active role in treatment process. For example, clarification of and elaboration on materials by the psychotherapist would be administered in conjunction with self-delivered administration of bibliotherapy to facilitate and guide treatment throughout. The second category, minimal-contact self-help, refers to the psychotherapist or trained professional primarily playing a role in familiarizing the client with materials at the outset and subsequently minimizing their involvement to monitoring the client’s ongoing experience with intermittent check-ins. These first two categories fall into guided self-help, which may be delivered in person, over the phone, or via computerized communication (e.g., e-mail communication, website or computer program-delivered guidance, or smartphone applications). Conversely, self-administered self-help refers to interventions which rely on client or patient administration, without the benefit of a trained professional or psychotherapist’s introduction to self-help materials. The evaluation of treatment effectiveness is then, most often, limited to assessment-driven contact. This category of self-help is the type that is most often commercially distributed and is the least scientifically evaluated.

Other useful categorizations include didactic versus imaginative materials (Riordan et al. 1996) and individually delivered versus group administration. In some instances, the use of self-help materials may play a role in a stepped-care approach, or approach where a client’s first introduction to treatment efforts begins with self-administered self-help materials. An individual’s treatment and care is then “stepped up” as needed into increasingly more direct forms of treatment (e.g., check-in calls, telephone-based sessions, in-person sessions). Inversely, self-help programs may be applied in a form of “stepped-down” care. In other words, guided or minimal-contact bibliotherapy could be utilized as psychotherapists move toward termination and progressively extinguish a client’s reliance on in-person sessions and encourage self-efficacy in self-care. In this scenario, bibliotherapy could provide personalized evidence that consumers have the skill to select, maintain, and direct positive change independently. In addition to the varying levels of administration, the delivery of self-help materials will likewise vary depending on the preferences of the person, the role of clinical judgment where trained professionals are involved, and the accessibility of the self-help materials.

Modalities of Self-Help

The term bibliotherapy evokes images of written or printed materials. However, as time progresses and technology with it, self-help materials continue to adapt to fit the currently preferred audio formats (i.e., from cassette tapes, to CDs, to podcasts). Visual materials have also been developed to accompany treatment or serve as stand-alone applications (e.g., workbooks, videos, DVDs). Existing printed materials have been modified to fit our ever increasingly technology-savvy population by transforming workbook pages to online tablets or client workbooks to an audio format (e.g., Shah et al. 2014). Internet-based interventions have arisen and evidence for their efficacy is continuing to grow in the research literature. Even commercially available games (i.e., the Nintendo DS version of Brain Age) have been evaluated for their efficacy as a self-help memory training application (Presnell and Scogin 2015). Future directions in research should consider the efficacy of available phone apps aimed at preventative care (e.g., phone apps aimed at preventing the onset of clinically significant depressive symptoms).

Clinicians initiating treatment with new clients should consider the self-help methods currently used by their clients, as well as those implemented before they first sought professional psychotherapeutic treatment. Clinicians and clients alike will need to keep in mind the broad range of self-help modalities (e.g., books, videos, websites), as both may neglect recognizing and categorizing readily available materials as “self-help” (e.g., Weight Watchers, various websites providing psychoeducation on depression). With the advent of the smartphone, the varying levels of administration (i.e., client-administered, therapist-guided, and therapist-administered self-help) can likewise take on a more fluid and nuanced role in mental health treatment and the tracking of treatment progress. Moreover, the speed at which these resources become available to the public surpasses the research base’s ability to evaluate their efficacy. With the ready accessibility and near-universal adoption of personal electronic communication devices (e.g., smartphones, tablets), the rate of creation and distribution of self-help materials is expected to be exponential. The following section will discuss current clinical applications of self-help.

Clinical Application of Self-Help

The programs with the greatest evidentiary corpus tend to be those which lend themselves best to self-administration, such as cognitive behavioral approaches (Anderson et al. 2005). The range of self-help applications across the lifespan is quite large and covers much of the territory deemed appropriate for traditional therapist-administered treatments. Materials created and implemented to address issues related to depression and anxiety have received the most extensive review, but areas such as weight-control, sexual dysfunctions, addictive behaviors (e.g., substance abuse, smoking), and less obvious targets such as nail-biting also carve out a place in the literature. Contraindications for self-help and bibliotherapy, primarily based on clinical intuition and not empirical fact, include conditions such as schizophrenia, psychotic depression, and bipolar disorder. Other questionable candidates for self-administered intervention include those with a personality diagnosis, typified by ego-syntonic disorder, who may fail to see the applicability of the materials or have otherwise impeded ability to adhere to a self-directed regimen. For example, a person with narcissistic personality disorder will often perceive their behaviors, feelings, and values as ego aligned (in support of the goals and needs of their ideal self-image) and may see little to no utility for changing their behaviors, feelings, or values. Conversely, a person with a depression disorder (an ego-dystonic disorder) often has a poor self-image and behaviors, feelings, and values that are not aligned with their ideal self and may predispose to attempt the changes and activities outlined in self-help protocols. Client characteristics may also contraindicate the use of self-help programs. Visual ability and literacy or reading skills should be considered, especially when the material is presented in written form.

None of these contraindications preclude a person from pursuing a purely self-administered program. As Lehane (2005), a community psychiatric nurse in Cardiff, succinctly points out, “Book prescriptions are on the increase and general opinion appears to favor this change.” Whether a mental health professional actively incorporates bibliotherapy and self-help techniques into their service repertoire is beside the point. Self-help programs are available, and clients/patients, co-workers, and family members will use them. Unfortunately, there is practically no evidence on the efficacy of entirely self-administered programs. This is due in part to the logistics involved and the understandable reluctance of university IRBs to approve such research. Similarly, selection of evidence-based minimal-contact and psychotherapist-administered programs remains limited, but continues to grow as those in the field turn their interest toward selecting evidence-based treatments (those with randomized control trials establishing the effectiveness of the self-help program in treating or addressing the problem of interest). As a subset of the general population, the evidence for self-help programs targeted toward older adults is similarly limited. Thus, practitioners will need to base their recommendations largely on what is known to work with younger adults.

Individuals will continue to use self-help materials. Thus, psychologists in particular have a continued interest in evaluating the evidence for, selection of, and guidance of self-administered treatments, no matter their form and degree of professional involvement. “Psychologists are in a unique position to contribute to the self-help movement. No other professional group combines the clinical and research experiences that are part of the clinical psychologist’s educational background. Clinical psychologists are skilled in current therapeutic techniques, they have clinical experience and sensitivity, and they have the training to assess empirically the efficacy of the programs they develop. This would represent a most significant and new development in the area of self-help approaches to self-management” (Rosen 1982). As such, familiarizing oneself with the benefits, limitations, and varied administration of self-help therapies is of import to beginning and established psychologists alike.

Used in conjunction with other treatment options, bibliotherapy and related self-help efforts offer cost-benefit opportunities. A plethora of extant self-help materials are commercially available at relatively low cost and may be sifted through in pursuit of extending the reach of the clinician past the therapy room. Non-exhaustive resources (e.g., Norcross et al. 2003, 2013) have been compiled over time in an effort to guide the selection and implementation of bibliotherapy, but selection of material remains largely dictated by the clinician’s own familiarity with the material or, by extension, at the recommendation of their peers.

Evidence Base for the Use of Bibliotherapy with Older Adults

In the early 2000s, several systematic reviews were carried out evaluating evidence-based treatments for older adults. Several of these reviews found promising evidence for the continued use and further development and evaluation of bibliotherapies in this context. The review led by Scogin and colleagues was the only review team in a multi-team effort to establish evidence-based treatments in older adults to find bibliotherapy to meet evidence-based treatment criteria (Scogin et al. 2005). Specifically, though behavioral bibliotherapy and Internet-based cognitive behavioral therapy were deemed as promising (e.g., awaiting a second confirmatory controlled experiment), cognitive bibliotherapy was the only form of self-help with enough research for its establishment as an evidence-based treatment for depression. The systematic review led by the evidence-based treatment search for anxiety also found promising evidence for bibliotherapy treatment, but was unable to establish its effectiveness due to limited, controlled-experiment research in this field. These findings highlight the need for continued efforts to establish and evaluate bibliotherapy treatments in the population as a whole and within older adult populations specifically.

Depression

As previously discussed, the methods and interventions used in self-help largely span the same domains as seen in traditional psychotherapy, and cognitive behavioral models (widely defined) tend to be most frequent (a trend also seen in face-to-face delivery of psychotherapy). With respect to older adult clientele and the self-help materials for depression, there are several well-known self-help books that have been marketed and evaluated. Examples include self-administered self-help books with CBT-based models (e.g., Feeling Good, by Burns) as well as those that are more behaviorally based (e.g., Control Your Depression, by Lewinsohn) and therapist-administered client manuals (e.g., Dick et al. 1996). Additionally, CBT-based models of self-help have also been adapted or newly generated to be distributed specifically within research contexts to address issues experienced by older adults (e.g., improving self-care management in the frail elderly, improving sleep and preventing depression in rural older adults). Though further materials may be indicated in treatment of late-life depression, relatively few have received adequate scientific scrutiny to promote their recommendation beyond that which can be obtained through careful clinical judgment and solicitation of knowledgeable peers.

Anxiety

Meta-analyses suggest that self-help for common mental health disorders (e.g., depression, anxiety) can be just as effective as face-to-face therapy (e.g., Cuijpers et al. 2010). In addition to their documented efficacy, self-help treatments of anxiety, such as exposure and relaxation, have been applied in digital formats. Specifically, Internet-based treatments such as therapist-guided administrations with in vivo exposure (Andersson et al. 2006) and live versus Internet treatment of panic disorder (Carlbring et al. 2005) are on the rise. Instances that tender prime candidates for self-help treatments include situations where motivation to seek, or accessibility of, services is especially impacted. With the rising frequency in which computers, tablets, and smartphones are readily available and pre-existing in a client’s accessible environment, the applicability of providing in-home treatments (e.g., exposure and guided meditation from an off-site location) likewise increases. Problematic issues with a depression-related lack of motivation and clinically elevated worry or panic related to leaving one’s home (e.g., panic disorder, agoraphobia) may be especially indicated for self-administered or therapist-guided administration. Individuals suffering from these conditions may look to stepped-care approaches and consider self-administered treatment as at their own initiative or at the recommendation of their clinician or concerned family member. Truthfully, many individuals with varying levels of symptom severity may look no further than these commercially or electronically available treatments due to scarcity of, low trust in, or financial inaccessibility of local mental health resources.

Sleep Problems

Sleep problems, which can be treated with cognitive behavioral interventions, require the individual to apply what they have learned in a clinical setting to their sleeping environment. As such, it could be argued that a major aspect of insomnia-related problems lends itself well to various forms of self-help treatments. Specifically, CBT for insomnia (CBT-I) has been evaluated in pure, self-help formats. Comparisons to therapist-guided versions yield favorable outcomes as well. Though therapist-guided methods tend to produce greater positive change, CBT-I self-help methods serve as a viable first-line treatment (e.g., Rybarczyk et al. 2011). Self-administered and minimal therapist-contact CBT-I have also been shown to be effective in older adult populations (e.g., Morgan et al. 2012; Riedel et al. 1995), even in the context of chronic health conditions that likely acerbate the formation and endurance of sleep problems.

Memory Training

Memory or cognitive training is a good fit for various forms of self-administration. The material is largely didactic in nature and involves learning and practicing various techniques. One version of self-administered memory training involves instruction in several mnemonic techniques and has been evaluated in several experiments (Scogin et al. 1985; Woolverton et al. 2001). Techniques presented in this bibliotherapy approach include categorization and chunking strategies, the method of loci, and novel interacting images for remembering names. Self-administered memory training capitalizes on the finding that self-paced learning is optimal for older adults. Given the concern that many elders have for changes they experience in cognition, it is desirable to have multiple modes of training delivery including self-administered versions and variations on presently available technology. Examples of the latter include the “brain training” programs available through the Internet or digital means. Presnell and Scogin (2015) conducted an experiment on the Brain Age program and found that it produced direct effects on a speed of processing task but had no evidence of transfer effects to skills not directly trained. This is a finding often reported in the memory and cognitive training arena but serves as a caution that we should be circumspect in claims for the efficacy of these interventions.

Other Areas

In addition to the disorders and psychological well-being areas discussed above, self-help materials have been developed and evaluated by the psychological community. Unfortunately, the evidence base specific to older adults is quite limited in these other areas (e.g., assertiveness, death and grieving, sex) and will not be discussed at length here. Clinicians and other medical professionals in the position of recommending self-help materials are encouraged to solicit guidance from the existing evidence base for adults and cautiously extend their recommendations to older adults while being ever mindful that some mediums of self-help may better match the needs and style of younger cohorts.

Conclusion

Self-help resources should be considered, both for their clinical application and for their obvious continued appeal in community settings. One need not look further than their local bookstore to find evidence of self-help’s popularity. Conversely, one must look a bit further before one finds clinically relevant resources guiding the hand of the psychotherapist or other mental health workers, in selecting and recommending these resources to those we serve. Consequently, the responsibility is upon us to continue the evaluation of the utility, applicability, and efficacy of self-help materials, in their various formats of administration. We must ask ourselves, if we do not take it upon ourselves to apply our training, expertise, and clinical knowledge to the assessment of these materials, which qualified other will?

Cross-References