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We sat down with Professor Roz Shafran, Emeritus Professor of translational psychology at University College London, to discuss her new paper on best-practice implementation for guided self-help.

Guided self-help – in which clients work through a self-help workbook or computer course with the support of a trained ‘guide’ – is an important part of mental health services. Studies suggest that it improves access, and can be as effective as full therapy, but according to Professor Roz Shafran, there is a real lack of published information about the practical aspects of working as a guide.

Now, she and colleagues in the UK, Sweden, and Australia have written a paper which sets out exactly how to structure sessions, personalize interventions, and use progress monitoring to maximum effect. It covers the specific competencies that the person working as the guide needs, how to use supervision and manage risk, and also calls for increased recognition of the role within mental health services.

Access and empowerment

Studies have shown that guided self-help is effective for a range of mental health difficulties including eating disorders, depression, anxiety, pain and psychosis, says Professor Shafran.

It is usually cognitive-behavioral in nature but differs from traditional 'high-intensity' cognitive behavioral theray (CBT) in that the written material is the focus, sessions are shorter and treatment duration is typically around 6-8 sessions. Guides engage with their clients online, talking over the phone, through text messages or face-to-face, to support, encourage and empower them.

And, as guided self-help requires less time with a professional, it’s an efficient use of limited resources, said Professor Shafran. It can reach people who wouldn’t have access to traditional therapy, as well as those who don’t want to see a therapist.

“We know that most people don’t ever access therapy, it’s estimated that only 20% of people in Westernised countries who need it that do,” she said. “If you think of low and middle-income countries, there just aren’t the available qualified therapists. There are also people who don’t want to come to therapy but will pick up a book – that’s a really important role for the self-help intervention.”

Getting better quicker

The brevity can also make it an attractive option, she said:

“It’s [often] on the telephone, it’s empowering, [the client’s] very busy. Seeing a therapist lasts an hour and a full course of therapy is often at least 12 sessions. [But] guided self-help is six sessions, which are generally half an hour long. So, it’s briefer and many people prefer that.”

It can also be particularly useful for helping children who are experiencing mental health difficulties: parents can be taught to be the guide so that they can help their child at home.

“It can be advantageous when you have a child that doesn’t want to come to therapy – many still find it stigmatizing, it takes time out of their day, it labels them as different. Parent-led CBT for anxiety, pioneered by Professor Cathy Creswell in Oxford, means you don’t need the child there at all [because the parent is trained to be the guide],” she said. “That’s a massive advantage.”

Parents have to be onboard with the intervention – and if the parent has an anxiety disorder themselves it can be difficult for them, says Professor Shafran. But the advantage of parents-as-guides is that “they’re there all the time”, so if a child comes home and has been anxious at school “they can deal with it there and then and think of strategies [for next time]. It’s [also] empowering parents for when those children grow up and go through adolescence and have other difficulties. They have the strategies to know what to do. I think it’s a really good model and it demonstrates the versatility of guided self-help and who delivers it.”

Whittling down waiting lists

Within talking therapy services in the UK’s National Health Service, guided self-help is usually provided by psychological wellbeing practitioners, children's wellbeing practitioners, or assistant psychologists, while therapists with a recognized core profession (e.g. CBT therapists, clinical psychologists) provide ‘high intensity’ therapy.

Qualified therapists can also make use of guided self-help to reduce their waiting lists. Professor Shafran notes that “it can free up their case load, and if their client doesn’t respond, they can do full therapy. Even for private therapists, for people in the wider mental health services, there’s always a role for some guided self-help.”

Clients sometimes worry that if they engage in guided self-help and do not show improvement, it will impact negatively on them when they have face-to-face therapy: “People are worried that it will mean that they’ve got nothing new to say: they’ve done the formulation, they’ve done thoughts, feelings, behaviors, [and that the previous intervention] ‘steals their thunder’, but the limited available evidence does not support that.”

Back to basics

While Professor Shafran has been interested in guided self-help for a long time, the idea for the paper emerged while she and her PhD student, Emily Davey, were developing a low-intensity guided-self-help treatment for adolescents with eating disorders. Davey had some basic questions (e.g., when do you send the questionnaire? What do you do if they don’t do the questionnaire? Do you set the agenda first?), but when the pair searched for information, they drew a blank. “There was nothing written down or peer-reviewed,” recalls Professor Shafran. “We wrote the paper because we couldn’t find what we needed, and thought it would be useful for the wider psychological professions too.”

Without clear structures for questionnaires and agenda-setting, clinicians risk “guide drift”: failing to deliver the optimum evidence-based treatment despite having the necessary tools. The concept is similar to therapist drift, and guides are advised to use checklists to ensure they are adhering to the intervention. Professor Shafran argues that there should be less drift with guided self-help because it is materials-based: “Psychology Tools can help people stay on track because it provides the materials that are the focus of the evidence-based intervention, so there’s less drift.”

The paper also sets out the role and boundaries of those acting as a guide: instead of providing advice, they should be a sounding board for clients, and examples of things they might ask the client are given. The paper covers the timing of sessions, what to do when the client is not engaging, and how to get the best out of supervision sessions.

Not always obvious

There are probably several reasons that a best-practice guide hasn’t been published before. Professor Shafran speculates that “people just think it’s really obvious but nobody has actually articulated how to do it. We don’t always know how to do everything until it’s made explicit, so we hope that this paper will help people optimize the implementation of guided self-help, thereby improving outcomes and access to it. We wanted to know how to do it, and we wanted to help people do it. Hopefully it’ll be a helpful resource.”

For more information, Professor Shafran is happy for people to contact her via email: [email protected]