Low Intensity Guided Self-Help Interventions: Understanding Change

Low-intensity interventions (LIIs) aim to reduce mild-moderate distress associated with common mental health problems, such as anxiety and depression. To date, the vast majority of these interventions are based on the principles of Cognitive-Behavioural Therapy (CBT) and are delivered in guided self-help (GSH) or self-help (SH) format. Research shows that CBT based LIIs are effective at reducing anxiety and depression and in some cases are as effective as traditional face-to-face therapy. However, low intensity (LI) CBT does not always work for everyone and for some, the positive effects of LI CBT reduce over time. Offering clients choice about the intervention they receive is important for successful service delivery. Some research shows providing choice can improve therapy outcomes and satisfaction, however, there is currently a lack of choice for LIIs in primary care settings. Whilst not currently available for use in clinical settings, LIIs that do not rely on the principles of CBT have been developed. The first section of this thesis reviews the literature on these alternative LIIs in the treatment of common mental health problems. Eleven relevant studies were included. Each was assessed for quality; the interventions were described; and findings related to feasibility, acceptability and effectiveness were examined. Largely, these studies were of good quality. Eight studies examined interventions based on psychodynamic therapy (PDT), two used interpersonal psychotherapy (IPT) and one used cognitive analytic therapy (CAT). Most interventions were delivered over the internet with varying levels of support. Except for one, all interventions reduced symptoms to the same extent as LI-CBT and all studies showed that their interventions reduced distress. Many participants did not complete their intervention and this was most common in interventions with lower levels of guidance or support. Where new interventions were examined, these were felt to be feasible for use by clinicians and participants. Further research using clinical samples is recommended. Understanding how interventions lead to positive outcomes (mechanisms of change) is an important area of research which can help to improve interventions and service delivery. The second section of this thesis explored individual change across two different types of GSH interventions (CAT versus CBT). Seventeen individuals with successful outcomes following CAT-GSH and CBT-GSH were interviewed about the changes they had experienced. Results showed no differences in the types of change described, with both groups identifying emotional, behavioural, cognitive and relational changes as a result of their intervention. Using a method called thematic analysis, interviews were analysed and themes from both GSH intervention groups were compared. Regarding mechanisms of change, there were themes common to both groups, including the importance of offering tailored support, having a personal connection with the therapist and being personally committed to change. CAT-GSH completers uniquely reported on the importance of gaining insight to the origins of their anxiety as well as developing relational insight and change. CBT-GSH completers uniquely reported on the importance of understanding anxiety, learning new techniques to cope, and having supportive relationships. Limitations of this study are discussed alongside clinical implications and recommendations for future research.