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|Clinician's Digest - Page 3|
When Self-Help Isn't Helpful
The influence of the self-help book market, which generates more than $1 billion a year, reaches deep into our profession. A survey in 2000 by psychologist John Norcross found that 85 percent of therapists recommended self-help books to their clients. By far, the most popular self-help books are based on cognitive-behavioral therapy (CBT), and there's preliminary evidence that such books can be effective at relieving and preventing anxiety and depression.
CBT self-help programs for depression typically include a module that directs people to focus on their negative or unrealistic thoughts, which led clinical psychologist Gerald Haeffel of the University of Notre Dame to question whether such programs, when used by individuals who ruminate, might actually make matters worse. He suspected that such modules could "provide further fodder for ruminative tendencies," which research shows can create deficits in executive capacity, cognitive flexibility, task-switching, and problem-solving. Ruminators also seem to have more difficulty removing negative thoughts from their memory.
Haeffel's study, reported in the February issue of Behaviour Research and Therapy, divided 72 students at risk for depression and anxiety into three prevention groups. The first group used a workbook to record everyday events, along with their mood and accompanying thoughts, and note down evidence that both supported and refuted those thoughts. They then identified their thoughts as realistic or subjective and rerated their moods. This is a common module in CBT programs. The second group recorded only their realistic thoughts and the evidence that supported it. The third group used the workbook to practice their academic skills.
Haeffel found that at-risk college students who were prone to rumination in the first group significantly deteriorated after using the workbook to record both their realistic and unrealistic thoughts, and that the negative effects lasted for at least four months after completing the study. In a surprising finding, the students in group three, who used the workbook to develop their academic skills, did as well as those in group two, who used the workbook to record only realistic thoughts. Haeffel speculates that because the students were attending an academically competitive university, the academic skills workbook helped alleviate a significant stressor in their lives.
Haeffel advises therapists to avoid recommending self-help books for at-risk clients who heavily ruminate, or to modify them to eliminate any focus on negative, unrealistic thoughts. His study can be viewed not so much as a warning about CBT self-help programs, but as a useful refinement. Up until now, CBT for depression has been shown to help only about half the people who use it. By finding different ways of working with ruminators, the overall effectiveness of the CBT model might be considerably enhanced.