Self-Help Resources When Therapy Is Not Directly Accessible

Alişan Burak Yaşar, Psychologist Sude Kurt

Self-Help Books

This series of articles, which we prepared with psychologist Sude Kurt, consists of three parts. In the first part, I will discuss self-help books. Despite the increasing prevalence of mental disorders, it is known that only a small proportion of those affected receive treatment, while many people in need are unable to obtain help (Kessler et al., 2009). Self-help refers to actions aimed at helping or improving oneself without assistance from others. Today, people turn to psychology for advice and guidance on how to live their lives. This guidance generally focuses on specific psychological problems and choices in life. In the context of self-help psychotherapy books, self-help is described as a way of coping with personal or emotional problems without working directly with a professional, and any book that can serve this practical purpose is considered a self-help book. These books are written to help readers address certain mental health problems. They offer help on a wide range of topics, such as how to participate in activities to improve quality of life, how to cope with depression, how to communicate in healthy ways, and what people can change about themselves. For example, self-help books address themes from a cognitive behavioral perspective, such as having satisfying relationships, providing tools for understanding and developing communication skills, using these skills in close relationships and other settings, offering practical ideas for relaxation and rest in relation to working life to help manage stress, and building psychological resilience under difficult circumstances (Bergsma, 2008). Readers can read about particular experiences and apply the strategies they learn without having to ask others for help. Over time, self-help books improve a person's ability to find solutions to problems encountered in daily life. People may choose to read these books following a professional's recommendation, or the books may be integrated into ongoing psychological treatment (Campbell and Smith, 2003). It is known that 563 million dollars was spent on self-help books in the United States in 2000 (Paul, 2001; cited in Bergsma, 2008). In Western Europe, a section devoted to psychology is a prominent feature of almost every bookstore. This popularity may be explained by the low cost and ready availability of self-help books (Bergsma, 2008). It should be remembered that self-help books do not replace the need for therapy and counseling.

In a randomized controlled trial we conducted in Turkey with patients with depression and anxiety, we investigated the effects of self-help psychotherapy books based on cognitive behavioral therapy theories (‘Fark Et, Düşün, Hisset, Yaşa’, ‘Hayatı Yeniden Keşfedin’, ‘İyi Hissetmek’ and ‘Mutluluk Tuzağı’) on depressive symptoms. According to the preliminary results of this study, self-help books were significantly more effective in reducing depression scores than a placebo book and treatment as usual (Yaşar et al., 2020). In another article, I will discuss in detail this study, which we conducted to observe the long-term effects of self-help books developed within the framework of cognitive behavioral therapy.

Internet-Based Self-Help Systems

One effective way to bring mental health treatment to those who need it is to make internet-based interventions accessible and usable by large populations (Berger, 2014). Research on internet-based psychotherapy treatments, particularly for anxiety disorders, is growing steadily. These studies indicate that internet-based treatments and traditional face-to-face psychotherapy produce similar outcomes (Berger, 2014). Experimental comparisons have found no difference between internet-based treatments and face-to-face therapy (Anderson et al., 2013). But do internet-based treatments affect the therapeutic alliance? Patient ratings of the therapeutic alliance indicate that internet-based treatments are effective in establishing a strong therapeutic alliance (Berger, 2014). Internet-based psychotherapy interventions show promise for increasing access to evidence-based psychological treatments. Most internet-based psychotherapies are based on the cognitive behavioral model (Andersson, 2009). Internet-based cognitive behavioral therapy can be delivered via a computer or mobile device. With ongoing technological advances, it is becoming a rapidly expanding mode of intervention compared with traditional psychotherapy. It can be used to treat mild to moderate depression, obsessive-compulsive disorder, and anxiety disorders (Oromendia, Orrego, Bonillo and Molinuevo, 2016). Internet-based cognitive behavioral therapy has been shown to improve patients' functioning and reduce symptom severity (Hummel, van Lankveld and Oldenburg, 2017). An overall reduction in symptoms has been observed, particularly when therapist guidance is provided (Kobak, Wolitzky-Taylor, Craske and Rose, 2017). A study investigating the effectiveness of self-help internet-based cognitive behavioral therapy in treating depressive symptoms found that it could be used by most individuals with depressive symptoms, regardless of symptom severity or sociodemographic background, as an evidence-based first-step approach to treating these symptoms. It was found to be useful in increasing access to and availability of evidence-based treatment and reducing the cost of depression treatment. Although many people with depressive symptoms today prefer psychotherapy to antidepressants, high treatment costs can prevent psychotherapy from being used in practice. Another study recommended internet-based cognitive behavioral therapy as an effective alternative to face-to-face treatment. The study found significant improvements in 66% of participants with social anxiety disorder (Nordgreen et al., 2018). In light of these studies, internet-based cognitive behavioral therapy is thought to offer a means of providing easy, affordable access to psychological treatments and reducing their cost. (Karyotaki, Riper and Twisk, 2017).

Phobias and Mobile Apps

Animal phobias, which fall under specific phobias, are common in the community, and severe phobias can seriously impair an individual's functioning. Phobias are treated using a technique called exposure, in which clients are gradually brought into contact with the stimulus or situation they fear or that causes them anxiety. Exposure can be conducted in vivo, meaning in a real-life setting, or through imagery, referred to as in vitro. Although randomized controlled trials have demonstrated this technique's effectiveness in treating phobias, it has certain limitations. While there are many apps developed abroad for this purpose, I would also like to discuss PhobiAR, an app developed by a team in Turkey as a TÜBİTAK-supported project. This and similar apps aim to address the limitations of traditional face-to-face therapies through augmented reality (AR) technology. For example, AR technology makes it easier for therapists and clients to access environments that would otherwise be difficult for them to reach together. Because social settings are variable and complex, it may not be possible to expose a client to anxiety-provoking situations for the desired length of time. AR applications help control both the environment and the duration of exposure. For clients who experience intense distress during real-time exposure to an anxiety-provoking stimulus or situation and are reluctant to undergo exposure, exposure applications in virtual environments provide a safer setting, increasing engagement in treatment. Research shows that AR technology is as effective as real-life exposure and may offer an important alternative to traditional exposure techniques for both therapists and clients.

PhobiAR is an augmented reality app developed for use in treating phobias of cats, dogs, cockroaches, and spiders. Each animal type has its own set of scenarios. For example, the app features two different types of cats, and commands can make a cat walk toward the client, meow, or sit, or allow one or two cats to roam around the room. Used during therapy sessions with the HoloLens AR headset, the app allows these commands to be given by either the client or the therapist.

This technology, defined as the integration of computer-generated models into the real world through HoloLens or smartphones, means that clients are not isolated from the real world and can use their own hands and bodies, giving them a stronger sense of realism. The realism of the models used in PhobiAR also provides an important advantage for both therapists and clients.

Research and development work is continuing on PhobiAR, which was developed with TÜBİTAK support by Dr. Saadet YAPAN and Prof. Dr. Levent SÜTÇİGİL from the Department of Psychology at Hasan Kalyoncu University and Research Assistant Nihat Yılmaz ŞİMŞEK from the Department of Computer Engineering. The app will be available for purchase for professional use in June/July 2021.

The first versions of the PhobiAR smartphone apps have been released on the App Store and Google Play Store, and work to improve the apps is ongoing.

References

• Andersson, G. (2009). Using the internet to provide cognitive behaviour therapy. Behaviour Research and Therapy, 47, 175-180.
• Andersson, G., Hesser, H., Veilord, A., Svedling, L., Andersson, F., Sleman, O., Mauritzson, L., Sarkohi, A., Claesson, E., Zetterqvist, V., Lamminen, M., Eriksson, T., & Carlbring, P. (2013). Randomized controlled non-inferiority trial with 3-year follow-up of internet-delivered versus face-to-face group cognitive behavioural therapy for depression. Journal of Affective Disorders, 151, 986-994.
• Berger, T. (2014, October). Internet-based psychotherapy treatments. [Web article]. Retrieved from:
• Campbell, L. F., & Smith, T. P. (2003). Integrating self-help books into psychotherapy. Journal of Clinical Psychology, 59(2), 177–186.doi:10.1002/jclp.10140
• Hummel SB, van Lankveld J, Oldenburg HSA, et al.: [Efficacy of internet-based cognitive behavioral therapy in improving sexual functioning of breast cancer survivors: results of a randomized controlled trial](https://dx.doi.org/10.1200/JCO.2016.69.6021). J Clin Oncol. 2017, 35:1328–1340. [10.1200/JCO.2016.69.6021](https://dx.doi.org/10.1200/JCO.2016.69.6021)
• Karyotaki E, Riper H, Twisk J, et al. Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data. JAMA Psychiatry.2017;74(4):351–359. doi:10.1001/jamapsychiatry.2017.0044
• Kessler, R. C., Aguillar-Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., Ormel, J., et al. (2009). The global burden of mental disorders: An update from the WHO world mental health (WMH) surveys. Epidemiologia e Psichiatria Sociale, 18(1), 23-33.
• Kobak KA, Wolitzky-Taylor K, Craske MG, Rose RD: [Therapist training on cognitive behavior therapy for anxiety disorders using internet-based technologies](https://dx.doi.org/10.1007/s10608-016-9819-4). Cognit Ther Res. 2017, 41:252–265. [10.1007/s10608-016-9819-4](https://dx.doi.org/10.1007/s10608-016-9819-4)
• Kumar, V., Sattar, Y., Bseiso, A., Khan, S., & Rutkofsky, I. H. (2017). The Effectiveness of Internet-Based Cognitive Behavioral Therapy in Treatment of Psychiatric Disorders. Cureus, 9(8), e1626.
• Oromendia P, Orrego J, Bonillo A, Molinuevo B: [Internet-based self-help treatment for panic disorder: a randomized controlled trial comparing mandatory versus optional complementary psychological support](https://dx.doi.org/10.1080/16506073.2016.1163615). Cogn Behav Ther. 2016, 45:270–286. [10.1080/16506073.2016.1163615](https://dx.doi.org/10.1080/16506073.2016.1163615)

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This article was originally published on the web portal of Bilim ve Ütopya on April 20, 2021. As the portal has been taken offline, I am republishing the text here.