With or without a therapist: Self-help reading for mental health

Abstract

Objective:

To address a critical gap in health education scholarship by exploring the contexts in which self-help reading takes place, the motivations of self-help readers and the processes through which such readers engage with books on mental health.

Design:

Structured, in-depth interviews conducted with participants recruited through online classified advertisements.

Setting:

Self-help readers were recruited from the four largest cities in western Canada. The setting of self-help reading as an ‘intervention’ was as natural as possible, with readers being asked to reflect upon their recent experience of reading a self-help book.

Method:

Qualitative interviews conducted with 45 readers. Interview transcripts were analysed thematically.

Results:

Illustrative narratives are provided for two categories of readers: those who read in conjunction with direct therapeutic intervention and those who read without input from a therapist. Findings within both categories indicate a high level of diversity in terms of contexts, motivations and experiences.

Conclusion:

Understanding the diversity of readers and their experiences is an important prerequisite for health educators wishing to develop a critical and responsible approach to positioning self-help literature within the broader range of approaches to promoting mental health.

Keywords

Bibliotherapy mental health popular culture qualitative research self-help

Introduction

Self-help reading has become a popular way for people to learn about and address issues relating to mental health. Norcross (2006) claimed that more US residents ‘will read a self-help book than visit a mental health professional’ and that ‘most psychotherapists are already recommending self-help materials to their patients’ (p. 683). Williams (2003) reported the results of surveys estimating that between 6 and 9 out of 10 mental health practitioners in the USA and the UK utilise or recommend self-help resources (p. 172). Despite the prominence of self-help literature on bookstore shelves and lists of best-sellers, scholars of health education have devoted little attention to self-help reading. There are many reasons to be highly sceptical of the self-help industry: the absence of regulations, the uneven quality of publications and the profit-seeking motivations of publishers all pose substantial risks for people hoping to learn about or deal with mental health issues. However, the tremendous popularity of the genre, along with research showing that self-help reading may be effective in some circumstances (Cuijpers et al., 2010; Haug et al., 2012; Hirai and Clum, 2006; Lewis et al., 2012), makes the process of self-help reading worthy of critical examination by health educators.

This paper introduces scholars of health education to existing research connecting self-help reading with mental health issues and identifies a significant gap in such research: namely, the absence of empirical work exploring the experience of self-help reading from the reader’s perspective. It then addresses this gap through presenting the results of qualitative interviews undertaken with readers of self-help books about mental health. The results focus on the contexts and processes through which people access self-help resources for mental health, paying particular attention to the relationship between readers and mental health professionals. Through better understanding the perspectives of self-help readers, health educators can develop a critical and responsible approach to positioning self-help literature within the broader range of approaches to promoting mental health.

Existing research

Empirical research linking self-help reading with mental health issues has been based primarily upon either experimental methods or textual analysis. Over the past 20 years, meta-analyses have concluded that carefully designed experimental research provides evidence that self-help reading may be an effective mode of treatment for some mental health issues, whether undertaken independently or in conjunction with more conventional forms of therapy. Haug et al. (2012) analysed 56 published articles and concluded that self-help ‘is effective in the treatment of anxiety disorders’ (p. 443). Lewis et al. (2012) assessed 31 randomised controlled trials and concluded that ‘There is evidence that self-help interventions are effective in the treatment of social phobia and panic disorder’ (p. 20). Cuijpers et al. (2010) assessed 21 studies and concluded that ‘guided self-help and face-to-face treatments for depression and anxiety have comparable effects’ (p. 1953). Hirai and Clum (2006) reviewed 33 studies and concluded that when compared with ‘therapist-directed interventions’, self-help interventions were of comparable effectiveness for panic problems, but somewhat less effective for specific phobias and social anxiety (p. 108). Den Boer et al. (2004) analysed 14 studies and concluded that ‘bibliotherapy as a self-help treatment for emotional disorders such as anxiety and depression … is significantly more effective than placebos or waiting lists … and may be as effective as professional treatment of relatively short duration’ (p. 967). Marrs (1995) assessed 70 experimental studies and concluded that bibliotherapy was effective in treating conditions relating to assertiveness, anxiety and sexual dysfunction; moderately effective in treating depression; and less effective when dealing with weight loss and impulse control problems. Gould and Clum (1993) analysed the results of 40 studies and concluded that self-help reading, with or without therapist contact, was an effective course of treatment for issues including depression, fear-reduction and sexual dysfunction (pp. 181–182). Overall, despite the existence of numerous studies that found weak or no association between bibliotherapeutic intervention and mental health outcomes (see, for example, Mead et al., 2005), the results of meta-analyses indicate that self-help reading often produces outcomes comparable to traditional forms of mental health intervention.

While experimental studies have assessed the impact of self-help reading, textual analyses have explored the rhetorical structure and discursive strategies of specific self-help books and described affinities between those books and socio-cultural trends. Greenberg (1994) analysed numerous self-help books to interpret and critique ‘co-dependency’ and ‘recovery’ memes in American culture. Ryan et al. (1994) examined 15 self-help books and characterised them as presenting a ‘folk-psychoanalytic’ model of emotions. Lyons and Griffin (2003) deconstructed the textual representation of menopause in four self-help books published between 1992 and 1996. Woodstock (2007) analysed 62 books in her history and critique of the positive thinking messages in ‘psycho-religious’ self-help literature. Coyle and Grodin (1993) analysed the well-known Women Who Love Too Much in order to explore how the structures of self-help texts constrain the interpretations that readers develop in the reading process. Textual analyses have produced insightful interpretations of the messages of self-help texts, but they have not explored how such messages are actually adopted, embraced, resisted or adapted by consumers as they engage with them from the foundation of their diverse, pre-existing patterns of thought and action.

While experimental methods and textual analyses have dominated scholarly research about self-help reading, qualitative interviews have, in a few cases, been conducted to describe the experience from the reader’s perspective. Barker (2002) interviewed 25 women to explore the formation of ‘an illness identity’ through self-help reading about fibromyalgia syndrome. Bruneau et al. (2010) interviewed six women to explore the ‘helpfulness’ of self-help reading in the context of dealing with physical and mental health issues. Grodin (1991) interviewed 11 women to explore the complex meanings attributed by readers to self-help texts. Lichterman (1992) interviewed six men and nine women and concluded that readers of self-help psychology books ‘read the books ambivalently, and in ongoing relation to other frameworks for situating personal selfhood in a social context’. While such studies have produced interesting insights into the experience of self-help reading, they have been few in number, engaged small numbers of readers and not addressed the issue of how self-help reading relates to conventional forms of mental health intervention.

Existing scholarly literature has confirmed the effectiveness of self-help reading for a range of mental health issues and deconstructed the rhetorical strategies and discursive structures of the genre. What has been largely missing in previous studies is the interpretation of the experience of self-help reading, from the reader’s perspective. Why and how do people read self-help books? This question is particularly important for scholars of health education. Despite the fact that millions of adults each year read self-help books with the explicit intention of learning something about mental health issues, major health education journals have not published substantial research about such reading. The following section describes the methods used to address this critical gap in health education research.

Research methods and participants

This analysis of readers of self-help books for mental health is part of a larger research project. In 2012, interviews were conducted with 134 adults who had read a self-help book, in the areas of career success, interpersonal relationships or health and well-being, over the course of the previous year (McLean, 2013, 2014; McLean and Vermeylen, 2014; Vermeylen and McLean, 2014). Interviewees were recruited primarily through online advertisements placed in the ‘books’ sections of Kijiji websites for Calgary, Vancouver, Edmonton and Winnipeg. This study did not engage in systematic or random sampling procedures. Therefore, interviewees do not represent the full range of readers of self-help books, and findings cannot be generalised to the broader population of such readers.

Qualitative interviews were conducted via Skype calls, the exchange of email messages and online ‘chat’ software. The interviews contained identical questions regardless of the medium of communication and were organised into five main sections: motivation, learning goals, learning strategies, learning outcomes and impact. As documented in Appendix 1, questions were open-ended, encouraging participants to share their experience of self-help reading in their own words and with minimal direction. Interviews were transcribed verbatim or cut and pasted from chat software or Email messages. Participants completing interviews received a CAD 25 honorarium and are identified in this article by pseudonyms.

For the purposes of this paper, readers interested primarily in career success, interpersonal relationships or physical health issues were removed from the analysis. The 45 readers whose focus was primarily upon mental health issues represented one-third of the total number of interviewees. Of these readers, 37 were women. The mean age of the interviewees was 34 years, with the age range extending from 18 to 64 years. Participants to the study had relatively high levels of educational attainment. Just three interviewees had not graduated from secondary school, and just four had no further education beyond secondary school. In all, 12 interviewees had some post-secondary education, and 12 had completed a post-secondary diploma or degree. Six had some post-graduate education, and eight had completed a post-graduate degree. A total of 11 interviewees were students, 8 were homemakers and 4 were unemployed. Of those engaged primarily in paid employment, five worked in the field of education, three worked in information technology, three worked in retail stores, three worked as administrative assistants and one worked in each of the following occupations (totalling to eight): social worker, civil servant, financial analyst, entrepreneur, research scientist, fire and flood restoration technician, musician and flight attendant.

Data analysis was undertaken by cutting and pasting pertinent passages from all 134 transcripts into an Excel database structured so that each row represented a single case and each column represented a single variable of analytical interest. Initial analysis involved the coding of each variable to enable the summary and comparison of the predominantly qualitative data. Four members of the research team independently coded most variables, with team meetings held to achieve consensus about instances where discrepancies emerged in the coding of different team members. Initially, the focus of analysis was on the description of the experience of self-help reading (contexts, goals, reading practices, self-reported learning and self-reported cognitive and behavioural change) and the comparison of patterns of experience according to variables such as gender, age and type of book. Once mental health emerged as a key theme for a significant proportion of interviewees, analysis shifted from coding variables to interpreting narratives. Narrative analysis focussed on reconstructing, on a case-by-case basis, the experience of self-help reading as a form of mental health intervention, with attention given to engagement with mental health practitioners and others involved in the process of intervention.

Findings

Each interview in this study was focussed on the experience of reading a specific self-help book (see Appendix 2 for a complete list of titles and authors). Of the 45 participants, 40 claimed to have finished the entire book that was the focus of their interview. Interviewees reported high levels of engagement with the texts, with the following learning strategies being engaged in by the percentage of interviewees identified in parentheses: taking notes or highlighting passages in the text (47%), keeping a journal or undertaking written activities as suggested by the authors (44%), talking with family members or friends about their self-help reading (33%), reading the text more than once (31%) and engaging in subsequent, post-reading activities such as finding supplementary information online, or reading another book by the same author (11%). Less than one-fifth of interviewees engaged in no other learning strategy than reading the text a single time.

While assessing the effectiveness of self-help reading is not the focus of this paper, it is worth noting that the participants to the study tended to believe that their self-help reading did indeed ‘help’ them. All 45 interviewees claimed that they learned something of importance from reading their self-help book, 40 (89%) claimed that they changed something about their day-to-day life as a result of their reading and 31 (69%) provided reasonably concrete examples of actions they claimed to have undertaken in response to suggestions made by self-help authors. The high proportion of interviewees making such claims is interesting, but it should not be interpreted as evidence regarding the overall effectiveness of self-help reading. The sample of participants to this study was surely biased in favour of people having had relatively positive experiences with self-help reading. People having negative or indifferent experiences would have been less likely to see our recruitment advertisements and less likely to respond to them. Furthermore, the design of the research did not allow for the validation of outcomes claimed, or attributions made, by participants.

While interviewees’ narratives frequently referred to the positive impacts of self-help reading, it is important to note that this study was not designed to evaluate such impacts. Rather, this study was designed in order to provide a rich, qualitative portrait of why and how people read self-help books. Randomised controlled trials have assembled substantial evidence in favour of the potential for self-help books to be effective means of addressing issues relating to mental health; this article explores the processes through which people engage with self-help books, paying particular attention to the relationship between self-help reading and more conventional processes of mental health therapy.

The 45 interviewees engaged in self-help reading to address a wide range of mental health issues. About one-third (16 participants) reported some form of general emotional dissatisfaction or unhappiness. The other two-thirds reported more severe forms of mental health issues, with 17 struggling with either depression or anxiety, seven endeavouring to cope with loss or a traumatic experience, two having attention deficit disorder and one each dealing with anger, an eating disorder and compulsive shopping. The following sub-sections explore these readers’ experiences, according to whether or not their self-help reading was undertaken in conjunction with direct contact with a mental health therapist.

With a therapist

Nine interviewees reported undertaking self-help reading as an adjunct to receiving therapy from a professional practitioner. Three of these people were in therapy for anxiety or depression, one was coping with a recent divorce, one was coping with the recent death of her husband and one each was receiving therapy for an eating disorder, childhood sexual abuse, attention deficit disorder and anger-related issues. Five illustrations represent the diversity of these nine interviewees’ experiences. Gabriel, a 25-year-old financial analyst, reported reading Life without Ed because ‘My therapist specialised in eating disorders and had success with other patients when having them read this book’. He reported being ‘against reading it at first’ because ‘it was from the perspective of a woman’ and he thought he therefore ‘wouldn’t relate to it’. Gabriel overcame this initial hesitation, and eventually became quite engaged in his reading of the book:

I started to journal and write my thoughts and internal struggles like the author to help give a voice to my eating disorder. I attribute this to a large portion victory over this issue in my life. I also talked with my therapist, family, and close friends about concepts and goals from it often.

Gabriel indicated that he was impressed with the book because it ‘was written from the perspective of somebody who was struggling with an eating disorder and felt like something that taught from true experience, not like a textbook’.

While Gabriel was required to read a self-help book by his therapist, Gracia actively sought out self-help books through online searches on anxiety and depression. Gracia, a 30-year-old schoolteacher, read Feeling Good because she ‘was really big into avoiding medication as treatment’. She explained, ‘I wanted some insight into why I was feeling the way I was (anxious, depressed) and I wanted to find some ways to change how I felt’. Gracia reflected on the benefits of self-help reading in conjunction with conventional therapy:

Reading can be such a personal experience. It is a way for someone to seek some reassurance or answers in the privacy of their own home and without feeling judged. I feel like reading this self-help has allowed me to feel like I am getting treatment on my time. There were times where I would be struggling in the middle of the night and I couldn’t just call my therapist so pulling out my book and reading would make me feel like I was doing something to help myself.

She reported that her self-help reading helped her feel less alone in her struggles:

I feel like if there is a book written about my issue then therefore others must be feeling like me too if they are writing about it. Feeling like I am not the only one has helped me to feel like I am not going crazy.

Galina, a 29-year-old social worker, read The Dance of Anger. She explained the roots of her interest in the book: ‘My therapist pointed out that she thought I was stuck, specifically that I had poor boundaries. That is how I came to identify that there were areas in need of change’. Galina described the role of self-help reading in her dealing with anger management and interpersonal boundary issues:

I really liked reading about my issue because I could reflect upon my issue privately. In many cases it was better than talking to my therapist or anyone because I didn’t have to be clear in what I was thinking or feeling immediately. I felt less pressured and defensive because I was alone and my emotional walls were down. I think the non-threatening format of the book helped me to consider things that I may not have been receptive to on another format.

Galina credited her self-help reading with her becoming more assertive in her interpersonal relationships and better able to interpret her own emotions.

Angie, a 32-year-old homemaker, read The Language of Letting Go based on the recommendation of her therapist. She explained, ‘I had just left my husband of five years and I was seeking a way to come to peace with how that relationship ended’ and that her therapist ‘said that I would see myself in the stories in it and it would help me understand my own behaviours’. Angie described the process of reading the book with guidance from her therapist: ‘In my talks with my therapist we would go over different things that were going on during my week and she would often refer me to this book and get me to read sections to gain further insight’. Angie attributed very positive changes to her self-help reading: ‘Working through this book changed my life more than any other book I’ve looked at’.

While eight of the nine interviewees whose self-help reading has been described as ‘with a therapist’ undertook their reading in conjunction with therapy, one interviewee reported turning to self-help reading due to her dissatisfaction with a range of interventions provided by mental health practitioners. Orla, an 18-year-old student, described her motivation for self-help reading in the following terms: ‘I was sexually molested when I was younger and I needed help overcoming it’. She reported,

When I was 15, I wanted to commit suicide because the emotional pain from the attack was eating me up inside. I ended up walking into traffic and I got hit by a car. No physical damage occurred. For months afterward, I had to see psychiatrists, doctors, therapists, and just about everyone that thought they could help me. I felt pressured by them and I didn’t feel helped at all. That is when I bought the self-help book.

Orla claimed that self-help reading helped her overcome the stress she had been feeling due to her traumatic experience: ‘The stress of the attack had been making me physically sick constantly. I no longer get sick’. She reflected, ‘I just think it’s amazing that a simple book can make me feel so much better about myself’. Orla’s idiosyncratic experiences with mental health professionals and self-help reading cannot be interpreted as representing those of a larger population of patients or readers. However, her narrative does illustrate the tremendous diversity of pathways and processes through which people engage in self-help reading for mental health issues.

Without a therapist

Four-fifths of interviewees in this study engaged in self-help reading without the involvement of a professional practitioner. Two of these readers commented that they engaged in self-help reading because they could not afford face-to-face therapy. Cole, a 20-year-old administrative assistant explained,

I came to a point where I realised telling myself I need help for a somewhat severe depression isn’t going to help, only perpetuate my own laziness. Since I couldn’t afford a therapist, and consider myself a computer nerd, I jumped on Amazon and started reading reviews about some books.

Rather than choosing a book written specifically for depression, Cole read The Seven Habits of Highly Effective People. He attributed very positive change to his reading: ‘Instead of waking up and dreading the day, and praying for it to be over sooner, I wake up content with the knowledge that I need to tackle the obstacles in my day’.

In a similar manner, Gabriella, a 29-year-old graduate student, explained turning to self-help reading due to financial constraints:

I was looking for something because I knew that the support and advice my friends and family were giving me weren’t enough, and I honestly couldn’t afford therapy although I felt like I needed it. I thought if I could find a good book on healing after a breakup, it could help me.

Gabriella found The Journey from Abandonment to Healing through browsing the self-help section of a major bookstore. She claimed, ‘This book has absolutely changed how I think about myself: I don’t see myself as a failure in relationships any more’.

In contrast to Cole and Gabriella, the other 34 interviewees who read self-help books without the involvement of a mental health practitioner did not even mention therapists in their interviews. In 15 cases, interviewees mentioned that friends or family members had either recommended the reading of particular books or given them books to read. Of these cases, seven readers were addressing a general sense of emotional negativity in their lives, while eight were dealing with issues that they described in terms of anxiety, depression and coping with loss. The experiences of Melia and Adrien illustrate this form of self-help reading, whereby friends and family members played a role in the process of diagnosis and bibliotherapy.

Melia, a 44-year-old homemaker, had a friend give her The Mindful Woman. Melia described her reading goal: ‘My hope in reading this book was to change negative thought patterns and to focus on being less judgmental and to help me “be more present in the moment”’. She further explained,

Mostly hoping to change my incessant need to be sarcastic which I view as unresolved anger towards others and myself. And again, to stay in the present moment rather than brooding over the past or having fear about the future.

Melia claimed that her reading helped her to meditate more regularly and to foster ‘more compassion for myself and others on a daily basis’.

Adrien, a 20-year-old grocery store stock-person, approached self-help reading due to a more severe mental health issue: ‘I could hardly move, let alone think, when the panic attacks started’. He explained how he came to read Don’t Panic: ‘It was given to me by my aunt when she heard I withdrew from my college for panic attacks’. Adrien indicated that he did not finish reading the book, and that he did not take any steps to implement recommendations from the author. Despite this apparently lukewarm engagement with the book, Adrien indicated, ‘I’ve learned from it to not be as worried about things I do or say, and I’m a bit more confident when talking with others’. He reported becoming more able, in the face of anxiety-provoking circumstances, to ‘calm myself down mentally. Remind myself to not panic or feel uncomfortable, and that it’s not something to worry about’.

Friends and family members were not the only people encouraging interviewees to read self-help books. Delilah, a 24-year-old fire and flood restoration technician, reported reading Fish! A Proven Way to Boost Morale and Improve Results, through the recommendation of her employer: ‘While I was working for a company with low morale we were requested to read it’. Delilah reported that she did not have any learning goals when she started reading, but upon reflection ‘I found I was a negative person and didn’t enjoy my job and always looked at the negative side of things’. Despite not undertaking the reading on her own initiative, Delilah indicated making change as a result of that reading: ‘I tried to think of ways to make the monotonous tasks more enjoyable and went into work every day with more positive thinking’. Karlie, a 56-year-old schoolteacher, described reading The Artist’s Way in response to a suggestion received from the facilitator of a workshop she attended at a ‘local holistic clinic’. Karlie claimed to learn: ‘I can change my life and my happiness. It’s never too late for anything. Happiness comes from being peaceful within’.

While family members, friends, employers and educators sometimes had a role in recommending specific self-help books, 17 interviewees described more independent pathways to reading. As was the case with those whose reading had been guided by friends and family members, roughly half of these independent readers were addressing a general sense of emotional negativity in their lives, while the rest were dealing with issues such as depression, anxiety and compulsive behaviour. Fiona, a 29-year-old post-secondary educator, explained the context of her self-help reading: ‘I have often been stuck in negative thought patterns, including worry, anxiety and feelings of powerlessness. These patterns become particularly powerful when I am under stress’. She expressed the following reading goals: ‘I wanted to learn more about the psychology behind my feelings of discontent, and my desire to be a better and more authentic person’. To pursue these goals, she browsed a second-hand bookstore and found The Dark Side of the Light Chasers. Fiona reported a high level of engagement in the reading process, undertook journaling and subscribed to monthly newsletters from the author. Fiona claimed, reading ‘has raised my consciousness of my thought patterns and it has helped me discover ways to maintain more positive patterns. It does not always work and I still frequently catch myself being negative, but it has helped’. Of the other seven interviewees whose independent self-help reading related to a general sense of unhappiness, two read books about meditation, two read Christian-oriented books, two read self-help books oriented towards helping people make a range of changes in their lives and one read a book about menopausal transitions. These readers found their books either through browsing in bookstores or online, or through recommendations from self-help books they had previously read.

Nine interviewees independently accessed self-help books to address concerns that would commonly be associated with mental health therapy. Clive, a 28-year-old unemployed man, spoke about the context of his reading Stop Saying You’re Fine: ‘I was very depressed, and suffered from a great deal of anxiety; my life was not in very good shape to say the least’. Clive described his depression as including poor eating and sleeping habits, irritability and anger. He explained, ‘I was looking for new strategies to get my life back on track again, strategies for a solid foundation of healthy habits’. Clive reported that engaging in regular exercise and journaling were the most important changes he made as a result of reading:

I used to just write about whatever I was overwhelmed with and whatever was on my mind. It kind of felt like I was my own ‘therapist’ and like I had someone with whom I could talk to about anything negative that was going on.

He attributed very positive changes to reading: ‘I believe that the act of reading this book helped me to put the wheels in motion to get my life back on track again’. In addition to Clive, five other interviewees reported independently sourcing and reading self-help books to address what they referred to as ‘depression’.

Three other readers narrated self-help reading experiences in the context of specific mental health issues. Esme, a 21-year-old university student, explained, ‘Over-shopping had become a problem in my life, and I was looking for a structured way to defeat it’. She read To Buy or Not to Buy after learning about it on an over-shopping website. She described the severity of her compulsive behaviour by referring to going without food, lying to her boyfriend about her expenses, stealing money from her parents and shoplifting from stores. She claimed that self-help reading led her both to change her leisure-time activities to avoid shopping locations and to come to a new understanding of her behaviour: ‘I learned the psychological roots of my over-shopping habits, and the triggers that usual lead me to over-indulging’.

Jasmine, a 43-year-old homemaker, was struggling with her own and her daughter’s attention deficit disorder and read Survival Tips for Women with AD/HD. While Jasmine reported learning some practical strategies from the book, she stated that the most important impact of the book was a reduction in her sense of being alone: ‘I learned that there are plenty of ADD/ADHD women out there who are also trying to raise ADD/ADHD children. Sometimes I feel very isolated in that regard, and this book really helped’.

Tori, a 25-year-old educational coordinator at a science centre, read one of the most famous self-help books of all time: How to Stop Worrying and Start Living. She explained the context of her reading: ‘I decided to read it because I was feeling a lot of stress and worry about planning my wedding and about having to move unexpectedly. I was getting stomach aches and having trouble sleeping’. Her goal was to improve her sleeping patterns and health by better managing her worries. Tori claimed,

the main thing in my day-to-day life that was changed by this book is my way of thinking about problems and stresses. This book gave me real strategies to cope with worries that I can go through in a step-by-step way in my mind to eliminate them.

She was careful in attributing only part of the credit for her improved mental health to self-help reading:

One major thing I should mention about the impact of this book is that I no longer suffer from stomach aches and rarely find myself having difficulty sleeping. However, my wedding has now come and gone, so the effect of this book is likely not independent from the fact that the major stressor in my life when I started reading it has been removed.

The experiences of Tori, Esme, Jasmine and Clive illustrate the processes through which people access self-help books to engage in forms of do-it-yourself therapy, addressing issues that in many cases become the focus of therapist–patient relationships.

Discussion

The most notable aspect of the 16 narratives featured in the findings section is not so much the uniformly positive outcomes self-reported by the interviewees, but rather the great diversity of pathways to reading and processes linking reading with therapy. Among those reading ‘with a therapist’, self-help reading was in some cases therapist-prescribed and in some cases patient-initiated. Some readers positioned their therapist as a ‘partner in reading’ and others positioned self-help reading as somehow ‘better than’ or ‘more convenient than’ therapy itself. Among those reading ‘without a therapist’, some turned to self-help books because they could not afford conventional therapy; others had friends, family members or employers play a role in ‘diagnosing’ their problems and ‘prescribing’ bibliotherapeutic resources; and still others independently identified mental health issues and engaged in reading to address those issues. About half of the interviewees who engaged in self-help reading without the presence of a therapist did so for issues that may very well have merited direct professional intervention, while the other half did so in response to what appeared to be less intense feelings of dissatisfaction or unhappiness.

Collectively, the readers’ experiences narrated above provide important insight into the under-studied processes through which people, whether or not already engaged with mental health professionals, access and utilise self-help books. This exploratory and qualitative work complements existing research about self-help literature and mental health. The strength of experimental research has been in the specification of issues for which, and circumstance in which, self-help reading appears to be an effective form of mental health intervention. The strength of textual analysis has been in the interpretation of the structure and meaning of self-help texts, and in the identification of ways in which texts may contain messages beyond those explicitly claimed. The weakness of both major approaches to the study of self-help reading is the inability to describe the diversity of readers and reading experiences, and therefore to explain the impact or the meaning of self-help reading in the wide range of contexts in which such reading occurs.

The recent meta-analysis by Haug et al. (2012) illustrates the gaps in experimental research that may be filled by ethnographic or interview-based studies. Haug and colleagues identify an important range of factors that influence the impact of self-help reading on anxiety disorders: self-help treatment format (e.g. text, computer-based and Internet-based), comparison or control group characteristics (e.g. waiting-list, placebo and conventional forms of therapy), characteristics of the sample (e.g. age, gender and educational attainment), nature of the primary diagnosis (e.g. panic disorder, social phobia and generalised anxiety disorder) and the nature of guidance from a therapist (e.g. none, telephone contact and face-to-face contact). The control of variability along such lines enables experimental research to make important contributions to explaining the conditions in which self-help reading may be an effective approach to addressing mental health issues. However, it does little to help health educators understand or address the sorts of contexts in which a large proportion of self-help reading for mental health issues actually takes place – contexts such as those where no contact has been made with mental health professionals or those in which patients themselves initiate unguided self-help reading as an informal adjunct or alternative to therapeutic intervention.

In a parallel manner, the recent textual analysis by Philip (2009) illustrates the contributions and limitations of constructing authoritative interpretations of the structure and meaning of self-help texts. Philip analyses a popular self-help book on depression and argues that the book encourages its readers to ‘experience the joy of self-reliance’ (p. 159) and promotes ‘an image of the healthy individual as one who is rational, autonomous, productive, energetic, and self-disciplined’ (p. 160). Philip argues that self-help books relating to mental health issues are part of ‘a general shift away from state-run institutional services and towards more individualised health choices’ (p. 165) and that such books are actually ‘focused on transforming the depressed reader into an ideal liberal subject’ (p. 162). The deconstruction of meaning in self-help texts enables researchers to identify potential ancillary consequences and political implications of the reading process. However, it does little to help health educators understand the actual reception of such texts by actual readers who actively interpret meanings in diverse and creative ways.

Self-help readers are not simply passive recipients of authors’ messages, nor are they consistently guided by mental health professionals in the process of reading. As such, research that transcends the limitations of randomised controlled trials and authoritative textual analysis is needed in order to construct a full understanding of the processes and impacts of self-help reading. The findings reported in this article demonstrate the tremendous diversity of contexts, pathways and processes which characterise self-help reading. To this already diverse picture, Appendix 2 adds a further level of complexity. In short, the quality of self-help books varies tremendously. Some authors present well-structured arguments, developing advice and recommendations rooted in empirical research, professional practice or personal experience, and providing readers with meaningful resources to address mental health issues. Unfortunately, given that the publication of self-help books is a largely unregulated field of commercial activity, some authors present unhelpful advice, without a rigorous empirical foundation. Indeed, in some cases, self-help books are likely harmful, encouraging readers to embrace unrealistic or disempowering understandings of their lives or to purchase other products and services from which authors stand to profit.

Conclusion

This empirical study has enriched the understanding of self-help reading for mental health. It has directly given voice to the experiences of 16 readers, and it has characterised the experiences of a total of 45 readers. While methodological limitations prohibit drawing conclusions about the health outcomes experienced by participants to this study, one can draw valuable inferences from this study about the contexts and processes through which people access self-help resources for mental health.

Diversity is the word that best describes the experiences of self-help readers. In this study, readers were predominantly well-educated women, but they ranged widely in age and made a living through diverse means. Interviewees read books addressing a wide gamut of issues, ranging from a diffuse sense of dissatisfaction to acute struggles with anxiety, depression and compulsive behaviour. They came to self-help reading via two basic pathways, summarised as with or without mental health therapists. Within these pathways, there was significant diversity in contexts and processes of reading. Such reading was sometimes initiated by therapists, family members, friends or employers, and it was sometimes initiated by the readers themselves.

The practical implications of this study are two-fold. First, there is a need for further research into the impact and effectiveness of self-help reading as it is undertaken in various cultural contexts. To date, impact studies have been dominated by experimental designs that remove much of the naturally occurring variability in the reading experience. In order to truly assess the effectiveness of self-help reading for mental health, it would be important to design research that takes into account the uneven quality of books available for purchase, the risk of mis-self-diagnosis among self-help readers and the likelihood that a majority of self-help readers have not been diagnosed by a mental health professional. It would also be helpful to study the experiences of people whose lives are not helped by self-help reading and to explore the socio-cultural implications of the popularity of self-help reading in light of more collective, alternative forms of health education and health promotion. Finally, it would be useful to carefully assess the characteristics of more and less effective self-help texts.

Second, self-help reading is too prevalent to be ignored and too risky to be simply promoted without qualification. Experimental research has determined that self-help books are, in some circumstances, effective resources for learning about and addressing mental health issues. However, the diversity of contexts of usage, the uneven quality of the books and the unregulated and profit-seeking nature of the industry make professional practice guidelines for health educators very difficult to develop. Understanding the experience of self-help reading, from the reader’s perspective, is an important first step in developing a critical and responsible approach to positioning self-help literature within the broader range of approaches to promoting mental health.

Footnotes

Appendix 1

Appendix 2 Acknowledgements

The author would like to acknowledge the research assistance provided by University of Calgary graduate students Kristen Atwood, Jaya Dixit, Brandi Kapell, and Laurie Vermeylen.

Funding

Research for this article was supported by a Standard Research Grant from the Social Sciences and Humanities Research Council of Canada. Grant number: 410-2011-0324.

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