Can you help yourself out of depression? An exploration of mindfulness and acceptance-based self-help techniques – part two.
31st October 2022
Written by Ellie Sullivan, Assistant Psychologist.
In part one of this two-part blog, we explored the current prevalence of depression globally as well as in the UK. We considered the causes of depression as well as the correlation between the Covid-19 pandemic and a rise in depression cases. We discussed widely used treatments for depression (anti-depressants and psychotherapy) and evaluated their accessibility and efficacy. It was suggested in part one that whilst the commonly used treatments for depression have their benefits and uses, they were not always fully successful in long-term recovery or were not always readily available to certain individuals due to financial barriers or long NHS waiting lists. Thus, there is an evident requirement for alternative, accessible and effective treatments for depression. Part two of the blog will focus on evaluating mindfulness and acceptance-based ‘self-help’ techniques for the treatment of psychological distress as explored by Cavanagh et al (2014) in their meta-analysis and systematic review.
Self-help can be defined as “a focus of self-guided, in contrast to professionally guided, efforts to cope with life problems” (APA, n.d.). Self-help can involve self-reliance, in which one addresses such problems on one’s own (e.g. by reading self-help books), or it can involve collaborating with others to address shared concerns, as in self-help groups. (APA, n.d.). Such interventions can also be delivered by computer programme applications and in other audio, visual or multimedia formats. Whilst self-help strategies are economically attractive, it is important to understand whether they can work. Before Cavanagh et al’s (2014) study there already existed a limited yet promising research base. For example, CBT-based pure self-help interventions were found to benefit individuals with depression. However, Richardson et al (2010) argue that guided self-help may be more effective than pure self-help, despite little difference between them (Lewis et al, 2012). The evidence for the effectiveness of CBT-based self-help interventions appears positive, but the current enquiry is whether the benefits extend to the dissemination of other evidence-based therapeutic methods including mindfulness and acceptance-based approaches. Whilst pure self-help may be marginally less effective than its face-to-face comparators, it has the potential of a much greater reach as it is financially accessible. Other benefits to self-guided interventions include a potential reduction in stigma, ease of updating material as new evidence is released and increases in self-efficacy, learnt resourceful and self-agency skills. Although, there are some disadvantages worth considering; the removal of a group context and the absence of a responsive teacher and teacher-guided enquiry process. Both of which are deemed contributory factors for learning mindfulness and acceptance (Segal et al., 2013). Lastly, the benefits associated with self-help strategies may be overshadowed by the potential negative impact of social isolation connected with self-learning (Botella et al., 2009).
Nevertheless, Cavanagh et al (2014) were inspired to take a closer look at the evidence base for mindfulness and acceptance-based self-help approaches to see whether they could provide a meaningful form of relief for depressive experiences. Their review included the evaluation of self-help techniques characterised by either no or reduced practitioner input. The materials should aim to provide instruction, guide, and encourage the user to develop skills, manage their difficulties and make changes, rather than just delivering information. The format of the interventions included internet-based, computer applications, and book-based guides to mindfulness or acceptance. Cavanagh et al (2014) focused particularly on whether self-help interventions enhanced mindfulness and present-moment acceptance and whether these components were also linked to reduced severity of depression. Fifteen studies were included in the review all of which followed a randomised controlled trial design and compared a self-help intervention including mindfulness and acceptance with a no-intervention control group, waitlist control, a monitored online discussion forum, psychoeducation, or an active psychotherapy intervention condition. Overall, 2286 individuals took part in the studies included, 1416 of whom were assigned to mindfulness and acceptance-based interventions, and 870 to the control conditions. The discrepancy in numbers between the treatment and control groups was accounted for. The interventions lasted two to nine weeks and the mindfulness and acceptance outcomes were measured on widely used and well-evaluated scales and questionnaires including the Mindfulness Attention and Awareness Scale (MAAS) and the Acceptance and Action Questionnaire (AAQ-II). Finally, depressive symptoms were measured using well-established scales that have good psychometric properties (Cavanagh, 2014).
Overall, the studies report relatively high levels of engagement in the intervention conditions, but lower rates of treatment completion. Nevertheless, participants in the pure self-help conditions were found to have significantly higher levels of acceptance and mindfulness skills and fewer depressive symptoms post-intervention than those in control conditions. These findings suggest that self-help methods can develop mindfulness and acceptance skills and can lead to a reduction in depressive symptoms. It also supports the growing body of research highlighting the potential benefit of utilising self-help techniques for the dissemination of evidence-based interventions. Moreover, it echoes the literature from in-person mindfulness and acceptance-based approaches in which mindfulness and acceptance abilities are gained and psychological distress is significantly reduced in clinical and non-clinical groups. The literature collectively indicates that symptom outcomes are mediated by changes in mindfulness, self-compassion and/or psychological flexibility (Wicksell et al., 2010). This illustrates that in-person mindfulness and acceptance-based approaches help individuals to change their relationship with the content of their experience; one example may be helping people to experience negative thoughts as mental events rather than as truths (Segal et al., 2013). It appears fair to assume that the same or similar mediators may be involved in self-help approaches. However, some guidance may still be required to help ensure the psychological well-being of individuals with depression; larger effects were found in studies whereby some guidance was available compared to unguided self-help. In terms of format, there appeared to be no difference between internet and audio/book-based interventions allowing people to choose their preferred option. Lastly, engagement and accountability should be considered in the designing of self-help interventions.
Cavanagh et al (2014) help illustrate that mindfulness and acceptance-based self-help approaches may be a viable treatment option across a range of populations including community samples and groups experiencing both mental and physical health difficulties. However, the studies specifically targeting depression did not always recruit participants from mental health services thus the effectiveness of these interventions cannot be assumed. Keeping these limiting factors in mind, the findings to date are consistent with the efficacy of such tools in clinical and community samples, albeit the widespread implementation of them may be premature at this point. Ultimately, self-help techniques which promote mindfulness and acceptance are largely available and the research about the potential benefits is a growing area. Cavanagh et al (2014) have helped contribute to the research base; the findings suggest that success in developing mindfulness and acceptance skills can be gained through interventions that require little to no therapist resources. These interventions could be utilised for symptom improvement in both clinical and non-clinical populations. Further research is needed to decipher the mechanisms of change, generalisability, cost-effectiveness and optimisation of self-help mindfulness and acceptance-based materials. These interventions may complement and extend the reach of evidence-based practices to enhance wellbeing and reduce distress. Finally, whilst the research is in its infancy, the efforts thus far have highlighted that self-help mindfulness and acceptance may improve access to psychological support and combat the current mental health ‘crisis’ and the potential barriers to overcoming psychological challenges.
References
APA. (n.d.). Self-help. Retrieved May 3, 2022, from https://dictionary.apa.org/self-help
Botella, C., Garcia-Palacios, A., Banos, R. M., & Quero, S. (2009). Cybertherapy: Advantages, limitations, and ethical issues. Psychology, 7, 77-100.
Cavanagh, K., Strauss, C., Forder, L., & Jones, F. W. (2014). Can mindfulness and acceptance be learnt by self-help? A systematic review and meta-analysis of mindfulness and acceptance-based self-help interventions. Clinical Psychology Review, 34, 118-129.
Lewis, C., Pearce, J., & Bisson, J.I. (2012). Efficacy, cost-effectiveness, and acceptability of self-help interventions for anxiety disorders: a systematic review. British Journal of Psychiatry, 200, 15-21.
Richardson, R., Richards, D.A., & Barkham, M. (2010). Self-help books for people with depression: the role of the therapeutic relationship. Behavioural and Cognitive Psychotherapy, 38, 67-81.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based Cognitive Therapy for depression: A new approach to preventing relapse, 2nd Ed. New York: Guildford Press.
Wicksell, R. K., Olsson, G. L., & Hayes, S. C. (2010). Psychological flexibility as a mediator of improvement in acceptance and commitment therapy for patients with chronic pain following whiplash. European Journal of Pain, 14, 1059.e1 – 1059.e11.