Therapy Without a Therapist?

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It's widely recognized that a few sessions of cognitive-behavioral therapy (or CBT) can be very helpful in treating the anxiety and depression that so many people experience. However, many people don't have access to a CBT therapist—maybe none are close by, or they're not in the person's insurance network, or they're prohibitively expensive. It can also be difficult to take time off from paid work or child care every week to see a therapist.

If you're interested in CBT for anxiety or depression and you aren't able to see a CBT therapist, take heart—you may not need to. There are multiple options for doing CBT without a therapist, including self-help books and Internet-based treatment. Many studies have shown that self-directed CBT can be very effective.

For example, a review of 33 studies found that self-help treatment led to significant reductions in anxiety; another review of 34 studies on depression found similar benefits of self-directed therapy, particularly when the treatments used CBT techniques. Both reviews found that that, on average, the self-help treatments were moderately helpful. In other words, people who did the treatment felt substantially better—maybe not like "a new person," but a noticeably less anxious or depressed version of themselves.

Data from these studies also suggest that people who do self-help CBT for anxiety and depression tend to hold on to their progress over time, which is very encouraging. One of the major goals of CBT is for you to "become your own therapist" by learning skills that you can continue to practice after you've ended treatment. These studies show that people who learn CBT skills on their own can use these skills to keep feeling well.

Does this mean the end for therapists? Certainly not. One of the other findings from the studies above is that CBT with a therapist tends to be more effective than self-help CBT, so there can be an additional advantage to working with someone directly. Self-help treatment can also be done with a limited amount of input from a professional—for example, a brief phone call each week—which can provide an extra boost compared to self-help alone. I suspect that the added benefit from working with a therapist comes not only from having the input of an expert but also from having a caring person's consistent encouragement.

Self-help CBT is part of a movement toward stepped care, in which the goal is to match the intensity of treatment to a person's needs. Someone who is severely depressed and barely able to get out of bed is probably not a good match for self-directed CBT, and likely will need one-on-one treatment with a professional. On the other end of the spectrum, a person with mild to moderate anxiety or depression who is generally able to function well may be a good candidate for a less intense option like a book on CBT.

If you're interested in self-directed CBT, the Association for Behavioral and Cognitive Therapies maintains a list of books that they've given their "seal of merit." [If you'll pardon the self-promotion, I also wrote a book on CBT for anxiety and depression.]

The cognitive techniques found in my book and others include:

• Learning to identify your thought patterns.
• Discovering how your thoughts affect your feelings and behaviors.
• Determining if your thoughts are accurate.
• Replacing biased thoughts with more realistic ones.

Common behavioral techniques include:

• Scheduling activities for yourself that bring you enjoyment and a sense of accomplishment.
• Recognizing how your actions influence your thoughts and emotions.
• Planning ways to make the best use of your time.
• Breaking down big, daunting tasks into smaller, more manageable ones.
• Facing your fears gradually and systematically so they diminish.

As you probably noticed, these approaches are fairly simple and obvious. Indeed, much of what drew me to CBT in the beginning of my graduate training was how straightforward and intuitive it was, and these characteristics make it well-suited to self-directed therapy. As I've written before, what makes CBT effective isn't so much the novelty of the interventions but the systematic approach and emphasis on practice.

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You might consider the following guidelines if you decide to pursue self-help CBT:

1. Find a book that resonates with you. Different people are drawn to different approaches, tones, level of detail, etc. If the book feels like a good fit, there's a better chance you'll stay engaged with it.
2. Choose a book that is based on solid research. Self-help therapy takes considerable time and effort, so it's worth directing your energy toward a program that has a solid grounding.
3. Make room in your schedule to focus on the program. There are better and worse times to tackle therapy of any kind. While there's a good chance you'll always have competing activities, it's better to avoid times when you're truly overextended and the therapy is likely to get pushed to the side.
4. Follow the program as closely as possible. It's easy to be tempted to skip parts of a self-help program that we think won't work, or that we think we know already. One of the dangers is that if we find a program doesn't help, we won't know if it's because it wasn't right for us or because we only did two-thirds of it. Adhering to the instructions gives us the best chance of benefiting and knowing what actually works for us.

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In a time of high anxiety, rising depression rates, soaring healthcare costs, and limited insurance coverage for mental health, self-directed psychological treatments have many advantages. Completing a program that's right for you can lower your anxiety, improve your mood, and provide you with skills that you can use as often as you need them.