Friday, 5 February 2010

CBT-based self-help books can do more harm than good

Self-help books based on the traditional principles of CBT, including popular titles like 'CBT for Dummies', can do more harm than good, according to a new study. The risks were highest for readers described as 'high ruminators' - those who spend time mulling over the likely causes and consequence of their negative moods.

The new research focuses on the use of self-help books as a preventative intervention for people at risk of developing depression. Gerald Haeffel identified 72 undergrads at risk and allocated each of them randomly to work through one of three self-help books. A third of the students spent four weeks working through a traditional self-help CBT-based book, of the kind typically found in book stores, which involved learning the links between thoughts, behaviour and mood, as well as identifying negative thoughts and re-evaluating them. Another group of students followed a 'non-traditional' CBT-based self-help book, similar to the first but modified so that the task of identifying and challenging one's own negative thoughts was removed. The final group followed a book that taught academic skills such as time-management and memory aids.

Here's the bottom line: among students who tended to ruminate and who had suffered an increase in stress, those who followed the traditional CBT book displayed more depressive symptoms after the four-week study period than those who followed either of the other two books. At four-month follow-up, the traditional CBT study group as a whole tended to have more depression symptoms than the other groups, although high ruminating and stressed students in the traditional group remained the biggest losers.

Haeffel sounded some notes of caution - the findings may not generalise to non-student participants, the samples were fairly small, and the outcomes were based on depression symptoms, not clinically diagnosed depression. That said, the stressed, high ruminators in the traditional CBT group ended up scoring on the 'moderate' range of the depression scale at four-month follow up.

'The current results suggest that cognitive work-books as traditionally operationalised (and sold in stores) may not work for individuals who ruminate,' Haeffel said. 'For these individuals, a modified form of cognitive skills training that does not rely on identifying and disputing negative cognitions may be more effective.'

This latest warning about self-help comes after a study published in 2009 that showed use of positive mantras such as 'I'm a lovable person' can actually be harmful to people with low self-esteem.
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ResearchBlogging.orgHaeffel, G. (2010). When self-help is no help: Traditional cognitive skills training does not prevent depressive symptoms in people who ruminate. Behaviour Research and Therapy, 48 (2), 152-157 DOI: 10.1016/j.brat.2009.09.016

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

22 comments:

  1. Manuel3:25 pm

    Interesting research.

    I've a female friend that is very likely affected by clinical depression (she has suicidal thoughts), and I've passed to her the "CBT For Dummies" book. Maybe it can do more harm to her than good? I'm worried, she is all capable of committing suicide. For what I remember of that book, it suggests that the ABCD worksheet is not indicated for ruminators.

    What would be "a modified form of cognitive skills training that does not rely on identifying and dispute negative cognitions"? Books?

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    Replies
    1. Anonymous6:35 am

      If you are concerned about your friend committing suicide, I suggest you alert your mental health department and have her evaluated to see if she is a danger to herself. They can set her up with the proper treatment ASAP. If you are in the US, you want her held for evaluation for three days under a 5150. I hope she gets better soon. You are a wonderful friend for trying to help!

      Delete
    2. Anonymous2:40 pm

      Get "The Mood Cure" it's on Amazon. That book works.

      Delete
  2. Hi Manuel
    Thanks for your comment. First of all, please note that this is preliminary research on a small sample of university students. The findings may not generalise. If your friend is suicidal and you are worried for her safety I suggest that you or she seek urgent professional help/advice.

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  3. Anonymous10:14 am

    Well, if you can think better than the person who wrote the book, or the therapist in the chair opposite, it's not that easy to buy the comforting but false picture they are painting.
    One spots the flaws.
    I'm not depressed, I just have "Positive Illusion Deficiency": it comes from examining and breaking too many of them: not fit for purpose.

    I did have a very good psychiatrist who admitted this: "If you weren't so intelligent and observant, I could lie to you in a much more positive and beneficial manner."

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  4. Manuel2:07 pm

    Hi Digest,
    thanks for your suggestions, I'll seek professional help for sure.

    ReplyDelete
  5. A good reddit.com comment thread on this article.

    ReplyDelete
  6. Anonymous12:29 pm

    re Manuel's comment - "CBT for Dummies" is an excellent study aid, but the title has unfortunate undertones for someone whose self-esteem may be at rock bottom.

    I know of someone who went for psychotherapy on the NHS and was offered it as a work book. She took the title very seriously and it didn't do her a great deal of good.

    ReplyDelete
  7. Manuel1:41 pm

    Anonymous:

    I've used myself that book before passing it to my friend, so I don't think she'll take that "for Dummies" label too seriously. At least I hope so.

    ReplyDelete
  8. I think you really need to read Psych Central's rumination on this study to understand the possible implications: http://blogs.psychcentral.com/anxiety/2010/02/is-self-help-helpful-2/

    ReplyDelete
  9. "CBT for Dummies" and other self-help books like "The Anxiety / Phobia Workbook" can be helpful aids when COMBINED with in-person therapy.

    Let's also keep in mind that the unaffordability of psychotherapy renders such therapy a white, upper-middle class experience. Self-help books are one way whereby the less fortunate may partake of some of the advances in psychology. Let's hope too that they may be more rather than less benefited by such books.

    ReplyDelete
    Replies
    1. I agree with your first point. The second point contains a rather unhelpful generalization. I, and plenty of my colleagues, offer low-cost help to people - for instance, by operating a sliding fee scale. Many of us feel that it's the best way we can help; by staying outside the NHS we don't have to compromise the values of the treatment, but are able to reduce the fee.
      Unaffordability of psychotherapy? White, upper-middle-class experience?

      Delete
  10. Anonymous7:40 pm

    And the irony of a self-help book for people with low self-esteem called "CBT for Dummies." It's like Troy McClure (on the Simpsons) promoting his video for people with self-esteem issues, "Get Confident, Stupid!"

    ReplyDelete
  11. Anonymous11:44 pm

    Would this relate in any way to anxiety disorders with a person not really affiliated with depression?

    Anonymous, the irony there really is strong :\

    ReplyDelete
  12. I think that there is always going to be skepicism about self help but the truth is that many people do benefit from reading self help books. I agree that in some cases they can do more harm than good but is there a way of regulating the material? I don't think there is!

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  13. Anonymous5:28 pm

    What are some of these "non-traditional" cbt books the study is referring to?

    ReplyDelete
    Replies
    1. The non-traditional workbook used in this study was identical to the traditional workbook [based loosely on Mind Over Mood] but with one exception: it did not have participants identify and dispute negative cognitions.

      Delete
  14. might be better to forget this cbt in favour of wisemans "as if principle" postive actions not positive thinking!

    ReplyDelete
  15. Anonymous5:27 pm

    I can't get access to the paper but I would be interested to know if the authors investigated how many of the participants would actually have used these self help CBT manuals or had considered it in the past.
    Also drawing from the third wave of Cognitive therapy and possibly criticizing the CBT approach, does this give an example of the possible pitfalls of CBT. Does it demonstrate that aiming to control a thought, and manipulate it is not too effective. Over rumination etc. (obviously this is not a study looking at the validity and efficacy of CBT!)

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  16. Anonymous12:46 am

    There is a section on rumination in the book, page 178. Maybe depressed ruminators should read that first.
    Yes, rumination can be harmful.

    ReplyDelete
  17. There's a new updated list for 2013 of Books about self-harm at http://www.cuttingdepression.net/books-about-self-harm/

    ReplyDelete
  18. Anonymous8:23 am

    As a ruminator myself, I went through a self-help CBT book and quickly realised for myself that the techniques of identifying negative thoughts and pondering the reasons was just going to make things worse. I found that instead a combination of positive affirmations and replacing negative thoughts with positive ones when I first notice them helped immensely.

    ReplyDelete

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